Agenda - Council - 06/11/2002 - Laserfiche WebLink

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LC220 Rev06/95 Minnesota Lawful Gambling Application for Authorization for an Exemption from Lawful Gambling License For Board Use Only Fee Paid Check # Initals Date Recd Organization Name Street · I Previous lawful gambling exemption number /¢¢ " , City Slate Zip Code County Name of Chief Executive Officer of organization First Name I Last Name ~ame of Or;ganization TreaSurer First Name Last Name Daytime Phone number of CEO Daytime Phone Number of Treasurer I I Check the box below which best describes your organization Fraternal Veterans Religious Other nonprofR !Check the box that indicates the type ct' proof attached to this application by your organization: J--1 IRS letter indicating income tax exempt status E~]Certificate of good standing from the Minnesota Secretary of State's office I---iA charter showing you're an affiliate of a parent nonprofit organization .,~,;~'jbroof previously submitted and on file with the Gambling Control Board Name of Establishment where gambling activity will be conducted Street City State Zip Code County Date(s) of activity (for raffles, indicate the date of the drawing) / , Check the box or boxes which indicate the type of gambling activity your organization will be conducting J--'j Bingo ~ Raffles [] Paddlewheels I--'J Puff-tabs j--'J T~pboards Be sure the Local Unit of Government and the CEO of your organization sign the reverse side of this application. -92- For Board Use Only Date & Initials o£Specialist / ./ I I I I ! I I