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LG220 <br />Rev06/96 <br /> <br /> ('~bmihllnrt | For Board Use Only <br /> Minnesota <br /> La~ui <br /> I <br />Apphcatton forAuthor/~~ ~ Fee Paid <br /> Check ~ <br />~xempffon from La~ul Oambfing License <br /> Initals <br /> Date Recd, <br /> <br />Organ;~z.ation Name ...... <br /> <br />Street <br /> 7-~-~/ <br /> <br /> ..-Previus.4awf'ut 'gambling exemption <br /> number <br /> <br />City 8tare Zip Code County <br /> <br />Name of Chief Executive Officer of organization (CEO) <br /> ,t ,,..Name j Last N~ame <br /> <br />Name of Organization Treasurer <br />First Name Last Name <br /> <br />i/ <br /> <br />l I <br /> <br />Daytime Phone number of CEO <br /> <br />Daytime Phone Number of Treasurer <br /> <br /> ( ) <br /> <br /> I <br /> I <br />I, <br /> I <br /> I <br /> I <br /> I <br /> I <br />I' <br /> <br />Check the box below which best describes <br />your organization <br /> <br />r--i Fraternal <br />['-3 Veterans <br />F--I Religious <br /> <br />[] Other nonprofit <br /> <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />[--I IRS letter indica~ng income tax exempt status <br />[--I Certificate of good standing from the Minnesota Secretary of State's office <br />['--] A charter showing you're an affiliate of a parent nonprofit organbation <br />~ Proof previously submitted and on file with the Gambling Control Board <br /> <br />Name of Establishment where gambling activity will be conducted <br /> <br />Street City State Zip Code County <br /> <br />Date(s) of activi~ (for ra~es, indicate the date of the drawing) <br /> <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> [-3 *Bingo [] Raffles [] *Paddlewheels r"-I *Pull-tabs ~ *Tipboards <br /> *'Equipmen't f~r these activities must be'obtai~aed from a li~en~ci 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 /> <br />I <br />! <br />I <br />I <br />I <br />I <br /> <br /> <br />