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<br />. <br /> <br />. <br /> <br />. <br /> <br />From: 6516394034 Page: 2/8 Date: 5/16/2006 1:36:16 PM <br />L.UL,U AppliCatiOn Tor E::xempt t"'ermlt r-ee ~ou <br /> <br />. An .exempt permit may be issued to a nonprofit organization <br />conducting lawful gambling activity an five or fewer days. and <br />awarding less than $50,000 in prizes durings a calendar year. <br /> <br />; Organization Jnformation <br />organFt;n ns e <br />I' - , _ \ <br />ti '" <br /> <br />stre <br /> <br />. -. ---.....--- _...~ <br /> <br />Fee Paid .s-a <br />Check No. / 0 J-U <br /> <br /> <br />~" -..~ <br /> <br />w ,0. -\- \ <br />(~.v\- ~,~ C~. r <br />;-r C.R l,~ <br /> <br />_ ...r........f <br /> <br />Previous lawful gambling exemption number <br /> <br /> <br />:statelZip COde <br />In t\j .fS:.1 j <1 <br /> <br />L6 <br /> <br />Name of chief executive officer (CEO) <br />~rSt nam~. . {l I . Last nam,e <br />.e fA". .\ c '1 w: c ~-t ~--wk.<"r <br /> <br />Type of Nonprofit Organization <br /> <br />Type of nonprofit organization (oheck one) <br />o Fraternal 0 Religious <br />O. Veteriln .Q Other nonprotlt organization <br /> <br />Type of proof of nonprofit status - attach a copy (see instructions) <br />o Nonprofit Articles of Inoorporation or Certificate .of Good Standing - Minnesota Secretary of State's Office <br />o Internal Revenue Servloe ' . <br />o Affiliate of parent .nonprofitC!rganlzatlon (charter) <br />)2Sl Proof previ~usly submitted and on file with.the Gambling Control Board <br /> <br />Gambling Premises Information <br />Name premises ~here gam~g activity will be condl.lct~d (for raffles. list the site where the.draWing Will take place) <br /> <br />y tJ- ,/J7, ..re '-~ rn, ( e:. "~ . <br />Address (do not use box). City. Zip.Code ~unty <br /> <br />?3 40tf-/6/ M- A I\j~ l<A. ~I\/ ~~30 J ~4.ff1.,S-R <br /> <br />Date(!!) of-activity (for raffles, indicate the date of1!le dra~ng) OR~ if) <br />, . II 0\. / c;. b C\ <br />P1"""A. ... ~ -".. \ ).. ~ ? ~ .. -r "20 I( t'\ /1'>\ re <br />Checkthe box or boxes i:rt indicate the type of gambling activity your orga . 'on win be conpu g: <br /> <br />o *Bingo p;i Raffles 0 *PaddlewheeJs 0 *Pull-Tabs 0 *T/pboards <br /> <br />"Gambling equipment far pull..tabs, t1pboards, padcflewheel:i, and bingo O:!lngo. paper, harch:ards, ancfblngo ball <br />.selection ~evice} must.b~ obtained from.a distributor licensee! ~ythe Ganibfing Control Board. To find a licensed <br />distributor, go to www.gcb.statemn.us and c1lck.on LIst ofUcensed DistrIbutors. Or eall651~OO. <br /> <br />'ThIsform will ~ made available in alternative Yourname and and yourorganizalion's name the fcllowirnr, Bow members, staff of the <br />format ~.8.large'print,.BralUl!l) upon request and address will be'public information whenBoan:l whose work asSignment requires that <br />The Information requested -on this tonn (and received by1tle Board. AIIthe oIherinfcnnafion .they'have access to the information; the <br />any~nlS) w1Rbe l,lse(/'bythe GambBng that you provide wiD be.private data about you Minnesota'Oepar1mentof.P.ubIicSafely;the' <br />.CanlTal Board (Board):1o determine your. until the Bow issues your pennit. When the Minnesota "ttcmey General: the Minnesota <br />qualilicationsto be invclved in I8wfuI gambling Board issues.yourpennll,aR otthe Information .Commissioners of Adrninislralion. Finance, <br />activities" in Minnesota. YOI.I have the tight to u,at you have provided to the Board In the .and Revenue; the .MIMssota Legislative <br />refuse to supply the information requestect. processofapplyingforyoUrpermitwiDbecome Auditor. nationa/and intemational gambling <br />however. if you refuse to supply this PUblic. If the BO<lrd:does not i/OSue you <I regulato:yagendes;OInyonel1JtliUantloCOWt <br />Information. the Boar.chnay not be able to permit, all the information you have provided Older:; olherindividuals and agencies:that are <br />determine your qualiligErtions and. <15 il in thlil proceG$of$pplyirrg fora perrnitremaln$ s~yaUlhori%edbystateorfederallaw <br />COn$sqI,lSl1ce. may refuse to Issue you a private. with the exception of your name and to have accessto the informallon;.individuaJs <br />permit. If you supply-the Information yourorganization'snameandaddresswhich and agencies for which law or legal order <br />requested, the Board will be able to process will remain pUblic. - . authorizes a new use orsharing ofinforma1ion <br />your application. Prillallil data about you;are available only ta afterthisNoticewas given; and anyone with <br />.ycurlXlnsent. <br /> <br />Daytime phone number <br />'5' 2-~ t.( 3 Sl.s ~1 <br /> <br />'3~ u. 2- "= ~ 0"7 '1'-( <br />~Ir( <br /> <br />/ <br /> <br />/P'1.<'C, :~ <br />. (/, ,{ (.oJ ;. u...'vJ ,.. <br /> <br /> <br />This fax was received by GFI-FAXmakerfax server. For more information, visit: http://www.gfi.com <br /> <br />-- <br /> <br />-135- <br />