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LG220 <br />Rev06/95 <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 />Initals <br /> <br />Date Recd, <br /> <br />Organization Name <br /> <br />Street City <br /> <br />Name of Chief ~e~ive Offi~r of o~anization (CEO) <br />Fi~Name ! La~ Name <br /> <br />Name of O~anization Treasurer ~'~kk~ <br />Fi~ Name La~ <br /> Name <br /> <br /> IPrevious lawful gambling exemptiqn number <br /> <br /> · <br /> <br />state ~ip Code <br /> <br />County <br /> <br />Daytime Phone number of CEO <br /> <br />Daytime Phone Number of Treasurer <br /> <br />I <br /> <br />I <br /> <br />Check the box below which best describes <br />your organization <br /> <br />~ Fratemal <br />~ Veterans <br />r--] Religious <br />[F~ Other nonprofit <br /> <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br /> F-] IRS letter indicating income tax exempt status <br /> [--ICertificate of good standing from the Minnesota Secretary <br /> of State's office <br /> I-"']A charter showing you're an affiliate of a parent <br /> nonprofit organization <br /> [~=roof previously submitted and on file with the Gambling Control <br /> Board <br /> <br />Name of E~ablishment ~ere gambling a~ivity will be conduced <br />Street State Zip Code County <br />Date(s) of a~ivity (for raffles, indi~te 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 /> [~ Bingo [] Raffles ~ Paddlewheels [--] Puli-tabs ['-'] 'Hpboards <br /> <br />Be sure the Local Unit of Govemment 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 /> <br />