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LG220 <br />Rev05~96 <br /> <br /> Minnesota Lawful Gambling <br />Application for Authorization for an <br />Exemption from Lawful Gambling License <br /> <br /> · :7-] .., ,,. ---, -- .. · ._ . . '~ ~ <br /> <br />For Board Use Only <br /> <br />Fee Paid <br /> <br />Check # <br />Initals <br /> <br />Date Recd <br /> <br />Organization Name [~ :'~ ........ ~ .......... I Previous lawful gambling exemption number <br /> I <br /> Family Hope Services Incorporated <br />Street City State Zip Code County <br /> 3315 Fernbrook. lane North' Plymouth I~N 55447 Hennepin <br /> <br />Name of Chief Executive Officer of organization (CEO) <br />First Name I Last Name <br /> I <br /> Fred I Peterson <br />Name of Organizati0n'Treasarer <br />First Name Last Name <br />Ronald I Hinrichs <br /> <br />Daytime Phone number, of CEO <br />(612) 557-8670' <br /> <br />Daytime Phone Number of Treasurer <br /> · (612) 721-3180 <br /> <br />Check the box below which best describes <br />your organization <br /> <br />E] Fratemal <br />I--] Veterans <br />r-] Religious <br />~ Other nonprofit <br /> <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />~ IRS letter indicating income lax e~empt s~Js <br /> <br />[] C, erti~te of good standing from bhe Minneso~ Secretary of State's ot~ce <br />[] A charter showing you're an affiliate of a parent nonprofit orcjanb~ion <br />I--I Proof previously submitted and on file with the Gambling Control Board <br /> <br />Name of Establishment where gambling ac~vi~ will be ~nduct~ <br /> <br /> G~e Fair (Property of ~uck ~l~ey) <br />St. eet Ci~ S~te Zip Code Coun~ <br /> <br /> 8404-161st Avenue ~ ~o~ ~ 55303 ~o~ <br />Date(~) of activi~ (for ~es, indicate the date of the drawing) <br /> <br /> Au~st 8 <br /> <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> [-] *Bingo ~ Raffles [] *Paddlewheels I--] *PuIFtabs [] *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 /> For Bom'd Use Only <br />Date & Initi,ds of Specialist <br /> <br />./ / <br /> <br /> <br />