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Minnesota Charitable Gambling Control Board <br />Room N475 Griggs-Midway Building <br />1821 University Avenue <br />St. Paul, MN 55104-3383 <br />(612) 642-0555 <br /> <br />LAWFUL GAMBLING EXEMPTION <br /> <br />FOR BOARD USE ONLY <br /> <br />INSTRUCTIONS: <br /> <br />PLEASE TYPE <br /> <br />Submit request for exemption at least 30 days prior to the occasion. <br />When completing form, do not complete shaded areas. <br />Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be <br />returned with an exemption number added to the form. When your activity is concluded; complete the <br />financial information, sign and date the form, and return to the Board within 30 days. <br /> I Ucense Numbe~ {if currently or previously licensed) <br /> <br /> CHAPTER - DUCKS UNLIMITED NntT,zcensed' <br /> <br />Organization Name <br />METRO NOT[{ SUBURBAN <br />Address First National Bank in Anoka City, County, State, Zip Code <br /> <br /> Champlin Office - 217 E., Dean Av. I Champlin:~ I-lenn~p~n: <br />Chief Executive Officer's Name I Phone Number I Manager's Name <br /> Gary L. Schake I 421-3830 <br />Type of Organization <br />[] Fraternal <br />[] Religion <br /> <br />[] Veterans <br />~'~ Other Nonprofit Organization <br /> <br /> ~5316 <br /> Phone Number <br /> Gary T,. ,qch~k~ / 42!-3830 <br />If Other Nonprofit Organization (Check One) <br />[] IRS Designation <br />[] Incorporated with Secretary of State <br />~ Affiliate of Parent Nonprofit Organization <br /> <br />Name of Premises Where Activity Will Occur <br /> <br /> St. Anthony Gun Club <br /> <br />Premises Address <br /> Ramsey, Minnesota 55303 <br /> <br /> Games Yes No <br /> <br />Bingo <br />Raffles × <br /> <br />Paddlewheels <br /> <br />Tipboards <br /> <br />Puli-Tabs <br /> <br />Use of Profit <br /> <br />Gross Receipts Value of Prizes Expenses <br /> <br />Date(s) of Activity <br /> <br /> 9-12-87 <br /> <br /> Profit <br /> <br />Distributor From Whom Gambling Equipment Acquired <br /> <br />I affirm all jMr0~on subm_i~edA~the Board is true, accu- <br /> <br />Chief Executive Officer Signature Date <br /> <br /> Distributor's License No. <br /> <br />I affirm all financial information submitted to the Board is <br /> <br />true, accurate, and complete. <br /> <br />Date <br /> <br />Chief Executive Officer Signature <br /> <br /> ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY <br /> <br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice <br />that this application will be reviewed by the Charitable Gambling Control Board and will become effective 30 days from the <br />date of receipt (noted below) by the City or County, unless a resolution of the local governing body is passed which specifi- <br />cally disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30 <br />days of the below noted date. <br /> CiTY OR COUNTY TOWNSHIP <br /> <br />Name of Local Governing Body (City or County) Township Name (Must be notified when County is the approving body) <br />Signature of Person Receiving Application Signature of Person Receiving Application <br />Title Date Received Title Date <br /> <br />CG-00020-01 (4/86) White -- Board Canary -- Board returns to Organization to keep <br /> Pink - Organization Gold - City or County <br /> <br /> <br />