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I ~' CG220 <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br /> Minnesota Lawful Gambling <br />Application for Exemption from For Omoo O~On~y <br /> Lawful Gambling License <br /> <br />Fill in the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing. <br /> <br />.N, ame and Address, of O,r~anization <br />Organization Name Y~)l/-~~ -- I current/previouslicense number <br /> ('/'*" """ ' <br />S~e~l ..... ~--' J' "City ] ' -- ~ · State Z/pc ode <br /> <br />Jcurrent/previousexempt number <br />~ p~.~ County <br /> <br />Type of Non-profit Organization <br /> <br /> Number of years in existence J/~,~C Number of active members (must be age 18 and older) J ~'~ j <br />Check the box below which Indicates' Your ty'pe of organization - <br /> [] Fraternal [] Religious [] Veterans J~Other <br /> non-profit <br /> <br />Attach proof of nonprofit status' which shows that,/our organization has been r~onpmtit for the most r&cent three years <br />,,~RS designation ~ [] IncorPOrated with Secretary of State [] Affiliate et parent nonprofit organization (charter) <br />Gambling Site <br />Name of site whe~re a .c[i.'vity will take place <br /> _. ' ~'u_~ ........ d.//~ .................................................... <br /> · ~'~-, ~.. ~.'t~ .J/t;~/City '' To~vn'"s~ip State Zip code i ou,,~,ty <br />Street or <br /> <br />Date(s) of <br /> <br />How will profit be used: <br /> .., .. _; <br /> t ,' , ,-'"~ t~-,,~ "/ ! -- ._ _ , <br /> <br />I declare all information submitted tO the Gambling Control D/vision <br />is true, accurate, and complete <br /> <br /> execut~¢e offic'er"C'sig"nature - Date <br /> <br />Local Government A, cknowled~ement <br /> <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Division and will become effective 30 <br />days from the date of receipt by the city or county, unless the local government passes a resolution to specifically prohibit the activity. A copy <br />of that resolution must be received by the Gambling Control Division within 30 days of the date filled in below. Cities of the first c/ass have 60 <br />days in which to disallow the activity. <br />City or County Township <br /> <br />Township name <br /> <br />Signature of person receiving application <br /> <br />Title Date received <br /> <br /> Mall to: <br />Department of Gaming - Gambling Control Division <br />Mail Station 3315 <br /> St. Paul, MN 55146-3315 <br /> <br /> <br />