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d`NV_%V Minnesota Charitable Gambling Control Board LAWFUL GAMBLING EXEMPTION <br />/} Boom N.M 5510Grigg-3383 yBuilding i FOR BOgRD USE 0laY <br />1821 University Avenue <br />St. Paul. MN 55104-3383 <br />(612) 642-0555 <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. <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 number added to the form. When your activity is concluded: complete the <br />PLEASE TYPE financial information, sign and date the form, and return to the Board within 30 days. <br />Orylxe.tbn xemm <br />ART CENTER of Minnenct-4 <br />tewx.res awnvxranewx,romm <br />Mfdre.. <br />2240 North Shore Drive <br />Cov. County. Into, Zip Cod. <br />Wayzata, Hennepin, Minnesota 55391 <br />CNO Eiui Olfcn'e N. <br />Andrea Nasset <br />I Mon, NumMr <br />73-7361 <br />Mina..... N... <br />phone Nunter <br />Tnoxw Orp.naeeon <br />❑ Fraternal ❑ Veterans <br />❑ Religion 0 Other Nonprofit Organization <br />II GMMr Nonprofit Or.eniurixt IChep. One <br />fl IRS Designation <br />p Incorporated with Secretary of State <br />❑ Affiliate of Parent Nonprofit Or anization <br />N..of fox" a WYNr. Aptivh, will Go.., <br />ART rRNTRR Info Minnoi <br />initial of power, <br />12/3r <br />a«nisof .ou <br />2240 North Shore Drive, <br />We zeta MN 55391 <br />4, 5, 6 <br />Gams <br />Yes <br />No <br />Gross Receipts <br />Valw of Prizes <br />Expenses <br />Profit <br />Bingo <br />X <br />Raffles <br />R <br />Paddlewheels <br />X <br />Tipboards <br />X <br />Pull -Tabs <br />X <br />Ueeol Role <br />accu- <br />rate, and <br />true, accurate, and complete. <br />oNmhulp'. Lip. NN. <br />ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY <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 T TOWNSHIP <br />Gin.____ <br />/86 <br />V V. u..I—, I. eV <br />Pm. on ......� GJW'v Cnvu Gmmiv <br />