Agenda - Council - 01/14/1997 - Laserfiche WebLink

Home

I I I LG220 Rev06/96 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 Previous lawful gambling exemption number Street City 7 Name of Chief Executive Officer (~f organization (CEO) First Name I Last Name Name of Organization Treasurer First Name Last Name State Zip Code County Daytime Phone number of CEO Daytime Phone Number of Treasurer Check the box below which best describes your organization Fraternal Veterans Religious Other nonprofit Check the box that indicates the type of proof attached to this application by your organization: [---J IRS letter indicating income tax exem~ status [---J Certificate of good standing from the Minnesota Secretary of State's office I-"-J A charter showing you're an affiliate of a parent nonprofit organization [~ Proof 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) /7, Check the box or boxes which indicate the type of gambling activity your organization will be conducting [--] *Bingo ~ Raffles [--] *Paddlewheels ['--] 'Pull-tabs J~ *Tipboards *Equipment for these activities must be obtained from a licensed distributor Be sure the Local Unit of Government and the CEO of your organization sign the reverse side of this application. For Board Use Only Date &-Initials of Specialist · ,/ /