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LG220 <br />RevOB/9$ <br /> <br /> Minnesota Lawful Gambling <br />Application for Authorization for an <br />Exemption from Lawful Gambling License <br /> <br />For Board Use Only <br /> <br />Fee Paid <br />Check # <br />lnitals <br />Date Reed <br /> <br />Organization Name <br /> <br />Street City <br /> <br />Name of Chief Executive Officer of organization (CEO) <br /> <br />First Name I Last Name <br />Name of Organization Treasurer Daytime Phone Number of Treasurer <br />First Name <br /> i Last Name ' <br /> <br />State Zip Code County <br /> <br /> CEO <br /> Daytime Phone number of <br /> <br />Check the box below which best describes <br />your organization <br /> <br />i--] Fraternal <br />F-'I Veterans <br />~ Re~ious <br />E~{her nonprofit <br /> <br />Check the box that indicates the type of proof attached to this applicati~ <br /> <br />by your organization: <br />I--'3 IRS letter indicating income tax exempt s-tatus <br /> <br />~ Certificate of good standing from the Minnesota Secretary of State's office <br />[~ A charter showing you're an affiliate of a parent nonprofit organization <br />I'--] Proof previously submitted and on file with the Gambling Control Board <br /> <br />2¢ i;i; ! ;:~:¢; ;;¢!; ¢i¢ :P¢;~i;!¢;;;;;;;~¢¢/{ ;¢(i ;:¢;6 ~¢!{¢¢i¢¢;¢;;; !il i; !¢;ii¢:i} ¢;i ;;i;;i! ;{{; :;(;;;~¢; ;;{i; i;{; !! !;gl;;ii~;¢ ¢; :;¢;; !i;;(!¢;{~¢i!ii¢ ;i;;ii~!;i¢ ;¢;¢¢¢i¢¢f¢!~! ¢ i;6{(¢!i!~¢i¢!;!¢;i¢¢;;¢¢N¢;!¢:¢¢i!¢!i ;¢iiieP ¢;! ¢i!(~! i¢:i;!iilPii;¢ ii; :i¢¢H; !i;i;¢{!;i¢i;i!¢{; i; !¢ ;:i!;!i; {ill! ;!ii¢ ¢ i;:!¢ ¢;ii i!;i;!i iiii¢!~¢¢¢i¢¢;ii i(i;i¢;i9!ii;¢;¢i!; ii{iii¢i¢i';ii¢i!;;ii¢ i;il {!{i¢ii!i¢iP~ ! <br /> <br />Name of Establishment where gambling activity will be conducted <br /> <br />II <br /> <br /> .1' <br />County <br /> <br /> ,! <br /> <br />Street City State Zip Code <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 cor~ducting <br /> <br />*Bingo <br /> <br /> ~ Raffles [] *Paddlewheels E~ *Pull-tabs F-'] *Tipboards <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 Board Use Only <br />Date & Initials of Specialist <br /> <br /> <br />