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LG220 <br />Rev08/95 <br /> <br /> Minnesota Lawful Gambling <br />Appfication for Authorization for an <br />Exemption from Lawful Gambling License <br /> <br />For Board Use Only <br /> <br />Fee Paid <br />Check # <br /> <br />lnitals <br />Date Recd <br /> <br />Organization Name <br /> <br />Street <br /> <br />Name of Chief ~Ecutive Officer of organiza[ion (CEO) <br />First Name J Last Name <br /> <br /> ~ ¢' I gambling exemption number <br /> /~, <br /> Previous <br /> lawful <br /> <br />City State Zip Code County <br /> <br />Daytime Phone number of CEO <br /> <br />Ncime of OrganizatiOn Treasurer <br />First Name Last Name Daytime Phone Number of Treasurer <br /> <br />Check the box below which best describes <br />your organization <br /> <br /> [---] Fraternal <br /> ~ Veterans <br /> [--] Religious <br />,J~ Other nonprofit <br /> <br />iCheck the box that indicates the type of proof attached to this application <br />,by your organization: <br /> ~.IRS letter indicating income tax exempt status <br /> [~iCertificate of good standing from the Minnesota Secretary <br /> of State's office <br /> ~,A charter showing you're an affiliate of a parent <br /> [~nonprofit organization . <br /> roof previously submitted and on file with the Gambling Control <br /> Board <br /> <br />Name of Establishment where gambling ~ctivity will be conducted <br /> <br />Street City State Zip Code County <br /> <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br /> II - AU0 "' O0 <br /> <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> ~ Bingo [~ Raffles ~ Paddlewheels [] Pull-tabs [] '~pboards <br /> <br />8e sure the Local Unit of Government and the CEO o( your organization sign <br />the reverse side' of this application. <br /> <br />-136- <br /> <br /> For Board Use Only <br />Date & Initials o£Specialist <br /> <br />/ / <br /> <br /> <br />