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LG2.20 <br />Rev06/95 <br /> <br /> Minnesota Lawful Gambling <br />App/ication for A uth orization for an <br />Exemption from £awfu/ Gambling License <br /> <br />For Board Use Only <br /> <br />Fee Paid <br />Check # <br /> <br />Initals <br />Date Recd, <br /> <br />Organization Name <br /> <br />~treet ' <br /> <br />Name of Chief ~ecutive O~r of ~6ganization'(CEO) <br />Fi~ Name / La~ Name <br /> <br />Name of O~anization' Treasurer <br />Fi~ Name La~ Name <br /> <br /> IPrevious lawful gambling exemption number <br /> <br /> State Zip Code <br />City C~unty, <br /> <br /> Da~ime Phone number of CEO <br /> <br /> 1-3¢11 <br /> Da¢ime Phone Number of Treasurer <br /> <br />Check the box below which best describes <br />your organization <br /> <br />~ Fraternal <br />~ Veterans <br />l--'"1 Religious <br />~ Other nonprofit <br /> <br />Check the box that indicates the type of proof attached to this application! <br />by your organization: <br /> [] IRS letter indicating income tax exempt status <br /> [_~Certificate of good standing from the Minnesota Secretary <br /> of State's office <br /> ~-'~IA charter showing you're an affiliate of a parent <br /> nonprofit organization <br /> l~roof previously submitted and on file with the Gambling Control <br /> Board <br /> <br />Name of Establishment where gambling activity will be conducted <br /> <br />Street City State <br /> <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br />Zip Code County <br /> <br />Check ~'he box or boxes'which indicate the type of gambling activity your organization wili be conducting <br /> l-'-I Bingo ~ Raffles [] Paddlewheels l'""l Pull-tabs [] Tipboards <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 /> <br />