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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 /> <br />Check # <br />initais <br />Date Recd <br /> <br />Organization Name <br /> <br />Street <br /> <br />City <br /> <br /> IPrevious lawful gambling exemption number <br /> <br />State Zip Code County <br /> <br />Name of Chief Executive Officer of organization (CEO) <br />First Name I Last Name <br /> <br />Name of Organization Trea.~urer <br />First Name Last Name <br /> <br />~,~ ,~ Tf/D e..o f. Nonp..,rofJ <br /> <br />Daytime Phone number of CEO <br /> <br />Daytime Phone Number of Treasurer <br /> <br />Check the box below whichbest describes <br />your organization <br /> <br />J---J Fraternal <br />[~] Veterans <br />J---] Religious <br />J--DFOt h er nonprofit <br /> <br />Check the box that indicates the type of proof attached to this application <br />by Your organization: <br /> J---1 IRS letter indicating income tax exempt status <br /> [--]Certificate of good standing from the Minnesota Secretary <br /> of State's office <br /> J-'-JA 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 Establishment where gambling activity will be conducted <br /> <br />Street City <br /> <br />Date(s) of activity (for raffle~, indicate the date of the drawing) <br /> <br />State Zip Code County <br /> <br />Check the b~x or boxes whiCh indicate the type of gambling activity your organization will be conducting <br /> J---J Bingo J~_ Raffles J---J Paddlewheels J--] Pull-tabs J-'-] 'Rpboards <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 />