Agenda - Council - 11/24/1998 - Laserfiche WebLink

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Minnesota Lawful Gambling Application for Exempt Permit - LG220 Organization lnfo~'mation Organization name For Board Use Only Fee Paid " .. Check No, Initials Received, f / Previous lawful gambling exemption number So~.',~t~ X- o~l~sg-?g- Street City Name of chief executive officer (CEO) of organization First name . Last name State/Zip Code County Daytime phone number of CEO: ( /. ~- ~ ) q b q- ,S-S-as- Name of teasurer of organization First name Last name T.y. pe of. Nonprofit 0.rganizatiOn. Check the box that best describes your organization: F"] Fraternal I--] Religious {'"-i Veteran [] Other nonprofit organization Daytime phone number of treasurer. ( ~,~l ) Check the box that indicates the type of proof your organization attached to this application: []] IRS letter indicating income tax exempt status ' [] Certificate of Good Standing from the'Minnesota Secretary of State's Office r-'l A charter showing you are an affiliate of a parent nonprofit organization [~ Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information Name 'of premises where gambling activity wi'Il be condUCted (for rafflesl list the site where the drawing will take place) . Address (do not use PO box) . City State/Zip Code . County Date(s) of activity (for raffles, indicate the date of the drawing) /~.~a~.se' /~ /~99 " Check the box or boxes that indicate the type of gambling activity your organization will be conducting: [] 'Bihgo [~ Raffles [='] *Paddlewheels J--~'PulI-Tabs [] *Tipboards *Equipment for these activities must be obtained from a licensed distributor. This form will be made available in alternative format 0.e. large print, Braille) upon request. The information requested on this form will become public information when received by the Board, and will be used to determine your compliance with Minnesota statutes and rules governing lawful gambling activities, Page 1 of 2 7/98 I I I I I I I I I I I I I I I I I