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HUU -i.r ut3 le C7 LNIIDLLN,. t.UIV:ICUL DUHRL Minnesota Lawful Garnblin 0.l0Lb4u r .loi ur Page 1 of 2 06/03 LG220 Application for Exempt Permit Fee $50 Poe Board Use Only Feaf'aid Organization Information CheckNo. Organization name Previous lawful gambling exemption Saint John's Church of Little Canada X- 62005 -04 -001 number Street 1 City 380 Little Canada Road Little Canada State/zip code Min55fo a County Ramsey Name of chief executive officar (CEO) First name Last name Rev: :Robert Fitzpatrick Daytime phone number of CEO Include area code 651 484 -2708 Name of treasurer First name Last name same Daytime phone number of treasurer. Include area code Type of Nonprofit Organ!zatlon Check the item that best describes your organization: _ Fraternal XX Religious Veteran — Other nonprofit organization Check the item that indicates the type of proof your organization attached to this application: IRS letter Indicating Income tax exempt status Certificate of Good Standing from the MInnesota Secretary of State's Office X A charter showing you are an affiliate of a parent nonprofit organization _ Proof previously submitted and on fife with the Gambling Control Board Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, lis tmhe silt where the drawing will take place) School Building and Grounds Address (do not use PO box) 380 Little Canada Rd. City Little Canada Stale /zlpcode lvin 55116 County Ramsey Date(s) of activdy (for raffles, indicate the date of the drawing) Sunday, September 26, 2004 Check the item(s) that Indicate the type of gambling activity your organization will be conducting: „XX "Bingo Raffles (cash prizes may not exceed $12,000) ' `Paddlewheels xi, "Pull•Tabs _ "Tipboards 'Equipment forthese activities must be obtained from a Ileensed disthbutot. This form will be made available in altematNe format (I.e. large print, Braille) upon request, The informaton requested on,thls form (and any attachments) wilt be used by the Gambling Control Board (Board) to detarfnlre your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse tc supply the information requested; however, If you refuse to supply this Information, the Board may not be able to determine your qualifications and, a a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will be able to process your application. Your name and and your organization's name and addres veillbe public • Board whose work assignment requires information when recelved by the Board. ' that they have access to the information; All the other intimation that you provide the Minnesota Department of Public will be private data about you,unril the Safety; the.Minnesota Attorney General; Board Issues younpermk, When the Board the Minnesota Commissioners of Issues your permit, all of the Intimation Administration, Finance, and Revenue; the that you have provided to the Board in the Minnesota Legislative Auditor, national and process of applying for your permit will international gambling regulatory agencies; become public. If the Board door not Issue anyone pursuant to court order; other you a pemmit, ell the Information you have Individuals and agencies that are provided in the process of applying fora specifically authorized by state or federal permit remains private, with the exception law to have access to the infornaton; of your name and your organization's name Individuals and agenda for which law or and address which will remain public legal order authorizes a new use or sharing PrNate data about you are avallaole only to of Informetlon after thls Notice was given; the following: Board members, staff of the and anyone with your consent.