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Samsjin9 Con~ro~ Board Fax:6}2 <br /> <br /> Minnesota Lawful Gambling ' <br />Application for Au~horizab'on for an <br />Exempt/on from Lawful Gambling License <br /> <br />For Board Use Only <br /> <br />Fee Paid '" <br />Che:k # <br />Init ,tis <br />Date Reed <br /> <br />~treet City County <br /> <br />~'ame of Chief Executive Officer of organization (CEO) <br />=ir'st Name I Last Name <br /> <br />4ame otr.. gan-~.zation -[ r~_asurer <br />:irst Name Last Name <br /> <br />State Zip Code <br /> <br />Daytime Phone number of CEO <br /> <br />Daytime Phone Number of Treasurer <br /> <br /> <~,~ 4-~'- ~-~' 7 <br /> <br /> I <br /> I <br /> I <br /> m <br /> m <br /> m <br /> I <br /> i <br />m' <br /> <br />Check the bo;,: below which best describes <br />your organization <br /> <br />E~) Fraternal <br />F-q Veterans <br />[] Religious <br />'~Other nonprofit <br /> <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />[] ]RS letter indbalJng income tax exempt status <br /> <br />r-'] C, er~cate of gcx:x:t standing from the Minne...scta Secr~ of State's office <br />[] A charter shove, rig you're an affiliate of a parent nonprof,', organiza~on <br />~ Proof prevbusly submitted and on fi~e with ~e ~ling Control Board <br /> <br /> I <br /> I <br />I' <br /> <br />'~ame of E,stablishment where gambling activity_will be conducted <br /> <br />,'treet City / State <br /> <br />Date(s) of activity (for raffles, inc~¢~ate the date of the drawing) -- <br /> <br />Zip Code County <br /> <br />;hock the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> I---] *Bingo [~ Raffles [] *PaddlewheeJs I--"J 'Pull-tabs ~ 'Tipboards <br /> _~4~. ~(~/z~ , . <br /> *Eqdpmaut zor mesc actJvides must be obtained fi:om a ii~cn~ci clis~butor <br /> <br />;e sure the Local Unit of Government and the CEO of your organization sign <br />~e reverse side of this application. <br /> <br /> For Board Use Only <br />Date & Initials of Specialist <br /> <br /> ml <br />m <br />m <br />m <br />m <br />m <br /> <br /> <br />