|
'Ic o
<br />
<br />,RevO6/96
<br />
<br />r/
<br />
<br /> For Board Use Only
<br /> Minnesota Lawful Gambling .' '~ee Paid '"
<br /> Application for Authorization for an
<br /> Check #
<br /> Exemption from Lawful Gambling License
<br /> lnitals
<br />
<br /> "-'e".",'"'.n,'. ".',~'~,' 'C(r,~',','¢', w,, ';,;41',~,~,'~'"{~;~..;."",~ .Or. , .'c~ ..'v.': . '.' ~ .',' . ',?~'~'v"~;' ,?';n'."¢ ~' '~ ~,~,:.:.:~ °E;'r,~;o .~;,:+.'2~ ;,'~;;~.';:'"~ ~.~,"~'..' '.' M."~;:?.':';.~.y~:~.:~{,~:¢J.'~,~ ,4,~¢.1~..,~,~ ~,r~,- ~..,~,q~ -.
<br />.~',:',"~6' ...~.,z..;.~;,.s,:;.~.~,>~,,,~.;,,'.,';.x ~:^¢":",5 ~': ~.t.'... "~.:' '~ (4' .'e:~':;'¢~'.' '~-',"~!~;'-'"* ..... i~, '!,~)~%..c; :.~.~.~:.;'~.~¢2,>'.'.";r4~k '. ',.;,:i',"..v.'.',; ~ ~,%(.-;,'~,s..:-~... ~;~: .;~....~, ~;.a, :.'..~;¢..-. ..?,,~,~.,.'.,~:/':..,
<br /> /' ..,.. v .. ,,., ' .'.~ '.' ,,,'.-'.,'/'.',,"~','.' -~' ..... ~,,: "', ............ ', '.-...,,.'"v.v,',-.'.',.;.:.,.. ....,,'. ,r,-./.,,(.,,o'; ,;,,~.'..; ,.. ;-. ,..,.?y),,, k'"','t,.,.,. '4". ""." ;.,'r: J~..,'.t"-..,, .% ,~...',,',';.,',-:,.,.,p..',,...~ v~...,,'-,~'..~.';.5/:.¢~' :..
<br /> .,% ~.~- ,....¢ , ~ '-. :,,. ~.' ' ~', .',~'.'o". '," ~, ~ x(,,, ,: .~, ;.~' .' ,' '~,.-'" ;. ,' .,'..,.~o.. ~., ,,' ' '×'~'~:~ '^" ," "t<~,'~^',~, ,' ,," ;' ,' ~,'~ .... ,~,;k. ,~ >........ ,. ,.,.,~ .~
<br />....... ,..,>.,..~ a.~.~'zafi~,,,/~,~ afl a.,..,.,~,.k,. ..... , ....... :,., .. ,...;,,. ......... ,,..,o ......... ,,.-.:.,~ .......... ,,. ...... .,,,~0..,.,.,~,,..~._.~.....,,,.~.~:,,.:....,.,.,.
<br />~::'~,~:' ...... ~. "~.% 'v~:,'!;e~'..'.~!':;'~:".':'.. ~ ~,;~;.%b~;;~,;!~¢:-~,'~:..?.~./.~.v.%~;:4'.".'~'''. '¢'.;;/,k~ ~..':
<br />
<br />/,(rg aniz -~on Name ....
<br />~treet City
<br />
<br />ame of Chief ~ecutive O~cer of organ~ation (CEO)
<br /> i~t Name Last Name
<br />
<br />................ I.--P~evi~us-~vful-gambling
<br />
<br /> State Zip Code
<br />
<br />lame of Orgamzauon ] rea.surer
<br /> irst Name Last Name
<br />
<br />exemption number
<br />
<br />County
<br />
<br />Daytime Phone number of CEO
<br />
<br />Daytime Phone Number of Treasurer
<br />
<br />( )
<br />
<br />· ;heck the box below which best describes
<br />your organ,-orion
<br />
<br /> ~ Fraternal
<br /> ['7"] Veterans
<br />IF-1 Religious
<br /> i'~ Other nonprofit
<br />
<br />ICheck the box that indicates the type of proof attached to this application
<br />!by your organization:
<br />'[~] IRS letter i~crca~g income tax exempt status
<br />
<br />[~ C, eCdficate of gc,~21 standing ~m the Minnesota Sec~-e~y of State's office
<br />[--J A chafer showing you're an a~liat~ of a parent nonprofit organbadon
<br />~ Proof previously submitted and on file w~ the Gambling Control Board
<br />
<br />~me of Establishment where gambling aOJvi~ will be conduced
<br />
<br />t~et ~//4/ /A.j), ~-l/~X-Jy//O City S~te ZipCode
<br /> e(s) of activity (for raffles, indicate the date of the drawingS'
<br />
<br /> _ ¢:,: /¢¢7
<br />-~eck the box or boxes'which indicate the type of gambling activity your organization will be conducting
<br />'~ F'-I *Bingo I~ Raffles ]'--] *Paddlewheels F~ "Pull-tabs [~ 'Tipboards
<br />I .~ap.~t ::t-or t]:tese act{~acs mt.tst be'obt~ca from a li;e~:~ ~st:dbutor
<br />I
<br />
<br />County
<br />
<br />i sure the Local Unit of Govemment and the CEO of your organization sign
<br /> reverse side of this application.
<br />
<br /> For Boa.rd Use Only
<br />Date R: Initials of Specialist
<br />
<br />
<br />
|