Agenda - Council - 04/22/1997 - Laserfiche WebLink

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LG22.0 Rev06/96 Minnesota Lawful Gambling Application for Authorization for an Exemption from Lawful Gambling. License For Board Use Only Fee Paid Check # initbls '~ '.' - ·" ...D ate. iR.e_..cd ! ! Organization Name'- _Proy'r Previous lawful gambling exemption number Street City State Zip Code County ff ~ ~ B ~ rri ~h '-/~- ~/,E-,d'~.,-~,cc,z/ 5-s-3~ /.¢//~,~/ Name of Chief Executive Officer of organization (CEO) First~/~r kName . I Las~_~ Name of Organization lreasurer First Name Last Name Daytime Phone number of CEO Daytime Phone Number of Treasurer Check the b62 below which best describes your organization I--] Fraternal r--] Veterans 1'-] 'Religious ~ Other nonprofit Check the box that indicates the type of proof .a.!tached t° this application by your organization: ~ IRS letter indicating income tax exempt status' ~ Ce'flificate of goal...standing from the Mifin~J~ota'~c,~tary of State's office ~--] A charter showing you're an affiliate of a ~rent nonprofit organization ~ Proof. previo~!y submitted and on file with the Gambling Control Board Name of Establishment where gambling activity will be conducted '-- Street City ...State Zip Code Date(s) of actfvity (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 ~ *Bingo ~ Ra~es ~ 'Paddlewheels ~ *Pull-tabs ~ 'Tipboards *Equipment for these activities must be obtained from a licensed distributor :-..."': County Be sure th~ 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 / ./ JI