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LG240R <br /> (Rev. 1/21/93) Minnesota lawful Gambling <br /> Application for Authorization to Conduct an Excluded R~ffle <br /> (If your organization has been licensed or exempted in the <br /> current calendar year, you are not eligible to apply for excluded raffle) <br /> Fill in the unshaded areas of this application and send it to the <br /> Gambling Control Board at least 30 days prior to the activity <br /> <br /> . FOR BOARD USE ONLYi/::.:..' <br />organizationlnformation-" :':i;.: !:" 'i;' '. <br /> Organization '97't _ <br /> c <br /> .... . O':.'?FI ;..:;i;N .! iFT] ::i?.:. ::-NA;}'I: .: ;.." <br /> <br /> Type ot nofiprofft organization (check one): <br /> [] Fratemal [--! Veteran <br /> L-~ Religious ~ Other nonprofil organization <br /> <br /> Type of proof of nonprofit status attached (check one): <br /> <br />,~ Certificale of Good Standing - Minnesota Secretary of Siate's Office <br /> internal Revenue Service <br /> Affiliate of Parent nonprofit organization (charter) <br /> <br />! <br />I <br />I <br />I <br /> <br />I <br />I <br />I <br /> <br /> The value of all raffle prizes in a calendar year may not exceed $750 <br />Date of raffle drawing ~/'~/r¢~ ~ // <br />Total market value of raffle prizes $ ,4 .~' / <br />Name of person in charge of raffle /~/~l)/)~..;q'(; ,~r,/,~c'/...Xd'f] Phone ((/~/'-Z) <br /> <br />Name of premises " Received <br /> <br />I <br />! <br />I <br /> <br />Street Address <br /> <br />City '~('~ /'. /?t ~ OR County ~nd <br /> <br /> AUG <br /> ¢~ambling contro~ Board <br />Township <br /> <br />I <br />I <br />I <br /> <br /> The information provided above is complete and accurate to the best of my knowled~Te. <br />~,, C,l~ef Executive Offi~,er's signature Name (please pdnt) Date <br /> <br />I <br />I <br /> <br />Send the completed registration form yo~ organ/zation s proof of nonprofit status to: <br />Gambling Control Board White - Original <br />1711 W. County Roacl B, Suite 300 South Yellow o Board <br />Roseville, MN 55113 <br /> <br />I <br />I <br />I <br /> <br /> <br />