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<br />. ..;...... / <br /> <br /> <br />Minnesota Charitable Gambling Control Board <br />'.: Room N475 Griggs-Midway Building. <br />%1821 University Avenue""':' <br />. ,,}: St. Paul. MN 55104-3383 <br />(6121642-0555. <br /> <br /> <br />. INSTRUCTIONS: 1.' Submit request for exemption at least 30 days prior to the occasion. <br />2., When completing form, do not complete shaded areas until after the activity. <br />3. 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 numb~T:ad.ded to the form. When your activity is concluded; complete <br />PLEASE TYPE the financial information, sign and date the form, and return to the Board within 30 days. <br />Organization Name """ Number of,Members License Number {if currently or previously <br />Anoka:-Champlin Volunteer Fire Departmeril:............. \40" licensed) and lor permit number. X-02009-71 <br />-'\ ----...' <br />, <br />I <br />./t. <br /> <br /> <br />Address ." .- <br />2301 Third Avenue <br /> <br /> <br />State <br /> <br />Zip <br />55303 <br /> <br /> <br />MN <br /> <br />Manager's Name <br />raig Syring <br /> <br />Phone Number <br />~12 ;421-6619 <br /> <br />Chief Executive Officer's Name " Phone' <br />1>.lan Wells ", ~." (61,~1.~.~7-2799 <br /> <br />Type of Organization ',. \ ~, <br />o Fraternal 0 Veterans, \ _ '\. . <br />o Religion ~ Other Nonprofit Organization <br />Attach proof of three years existence. <br /> <br /> <br />Na.me of Premises Where Activity Will Occur <br />St. 1.nt.~ony Gun Club <br />Premises Address <br />16128 N.W. Variolite St. <br /> <br />Game Yes No <br />Bingo X <br />Raffles X <br />Paddlewheels X <br />Tipboards X <br />Pull-Tabs X <br />Use of Profit <br /> <br />If Other Nonprofit Organization ICheck One and attach proof of nonprofit status), <br />~ IRS Designation <br />o Incorporate with Secretary of State <br />o Affiliate of Parent Nonprofit Organization <br /> <br />Date(s) of Activity, drawing Is) <br /> <br /> <br />September 11, 1988 <br /> <br />. " taJfirm all information submitted to the Board is true, accor- <br />ate, and complete. <br /> <br />.:::~~~-:-07""'''' <br /> <br />-:;;:: <br />,'-- , <br /> <br />./ ,','..-" <br />/~-.;;--~~. '. <br /> <br />Date <br /> <br />~.:Ch_!e.! EX~cutrv'e;-qcf!ic'er Sig'~~iure.~~~~~~1\?1~S~~~f~~~~~~7;~fe);D'~t~~. <br /> <br />Chief Executive Officer Signature <br /> <br />6-8-88 <br /> <br />ACKNOWLEDGEMENT 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 th~ Charitable Gambling Control Board and will become effective 30 days from the <br />date of receipt (noted below) by the City o(County, unless a resolution ohhe 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. 1 <br />CITY OR COUNTY TOWNSHIP <br /> <br />White - Board <br />Pink - Organization <br /> <br />Name of local Governing Body (City or County) <br />-C ;iy of R""...'\[.~'f <br />Signature of Person Recer..ing Application <br /><----;;'l,..~ i.... , ^ . _--4- <br />{/ / --....,....d-{~~--- <br />Title <br />P e ( ; c r C l....; (-' .( <br /> <br />CG-00020-01 (6/87) <br /> <br />Township Name (Must be notified when County is the approving body) <br /> <br />Signature of Person Receiving Application <br /> <br />,. <br /> <br />y Da.l~ ';(ceived <br />.9-9.~o <br /> <br />Title <br /> <br />Date <br /> <br />Canary - Board returns to Organization to complete shaded areas. <br />Gold - City or County <br /> <br />4 <br />