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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 />Organization Name <br /> A N ~ K A-C 1 t A <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 re.maining 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 /> <br /> License Nurnbe~ (if current~ or previously licensed) <br />MPL[N FIRE D~PAIUj'MENT I X-02-009-1~(5 ; <br /> <br />Address <br /> <br />23[)1 Third Avenue <br /> <br />Chief Executive Officer's Name <br /> Alan Wells <br /> <br />Type of Organization <br />[] Fraternal <br />[] Religion <br /> <br />City, County, State, Zip Code <br /> Anoka, Ar, oka, Minnesota 553li3 <br /> <br />IPhone Number <br /> (612) 427-27s9 <br /> <br />[] Veterans <br />[~2bther Nonprofit Organization <br /> <br />Manager's Name <br /> John J{olF, les <br /> <br />Phone Number <br /> <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 /> bio /',l~thon¥ (Jun Club <br /> <br />Premises Address <br /> 15128 N.~:. Variolite :;treet <br /> <br /> Games <br /> <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Puli-Tabs <br /> <br />Use of Profit <br /> <br />Gross Receipts Value of Prizes Expenses <br /> <br />Date(s} of Activity <br /> <br /> Profit <br /> <br />Distributor From Whom Gambling Equipment Acquired <br /> <br />I affirm all information submitted to the Board is true, accu- <br />rate, and complete. <br /> <br />Chief Executive Officer Signature <br /> <br /> IDistributor's License No, <br /> <br />I affirm all financial information submitted to the Board is <br />true, accurate, an~ complete. <br /> <br /> Date Chief Executive Officer Signature <br /> <br />ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY <br /> <br />Date <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 /> <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) <br /> <br />Signature of Persbn Receiving Application / <br />Title Date Received <br /> <br />CG-O0020-O 1 (4t86) <br /> <br />White - Board <br />Pink - Organization <br /> <br />Township Name (Must be notified when County is the approving body) <br /> <br />Signature of Person Receiving Application <br /> <br />Title Date <br /> <br />Canary -- Board returns to Organization to keep <br />Gold -- City or County <br /> <br /> <br />