Laserfiche WebLink
LG220 <br />Rev06/96 <br /> <br /> Minnesota Lawful Gambling <br />Application for Authorization for an <br />Exempt[on from Lawful Gambling License <br /> <br />For Board Use Only <br /> <br />Fee Paid <br /> <br />Check # <br />Iniials <br />Date Recd <br /> <br />Organization Name <br /> <br />Previous lawful gambling exemption number <br /> <br />Street <br /> <br />Name of Chief Executive Officer of organization (CEO) <br />First Name I Last Name <br /> I <br /> <br />City State <br /> <br />Zip Code County <br /> <br />Daytime Phone number of CEO <br /> <br />Name of Organization Treasurer Daytime Phone Number of Treasdrer <br />First NaCne Last Name <br /> <br />Check the box below which best describes <br />your organization <br /> <br />r-~ Fraternal <br />i--ri veterans <br />~ Religious <br />~ Other nonprofit <br /> <br />Check the box that indicates the type of proof attached to this application <br />Dy your organization: <br />[--'1 IRS letter indicating income tax exempt status <br /> <br />~ Certificate of good standing frorp, the Minnesota Secretary o[ State's office <br />~ A chartershowing you're an affiliate of a parent nonprofit organization <br />~ Proof previously submitted and on file with the Gambling Control Board <br /> <br />Name of Establishment where gambling activity will be conducted <br /> <br />Street <br /> <br />City State Zip Code County <br /> <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> E~ *Bingo ,~ Raffles E~ *Paddlewheels ~-J *Pull-tabs ~7] *Tipboards <br /> <br />*Equipment for these activities must be obtained ,from a licensed distributor <br /> <br />Be sure the Local Unit of Government and the CEO of your organization sign <br />the reverse side of this application. <br /> <br />-16- <br /> <br /> For Board Use Only <br />Date & Initials of Specialist <br /> <br /> <br />