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Minnesota Lawful Gatnblin Page 1 of 2 06/03 - LG220 Application for Exempt Permit Fee $50 For Board Use only Feef aid Organization Information CheokNo. Organization name Previous lawful gambling exemption Saint John's Church of Little Canada X- 62005 -04 number -001 Street 380 Little Canada Road City Little Canada State/zip code Mn. 55117 County Ramsey Name of chief executive officer (CEO) First name Last name Rev. Robert Fitzpatrick Daytime phone number of CEO Include area oode 651 484 -2708 Name of treasurer First name Last name same as above Daytime phone number of treasurer. Include area code Type of Nonprofit Organization Check the item that best describes your organization: _ Fraternal ,, Religious Veteran _ Other nonprofit organization Check the item that indicates the typo 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 XX A charter showing you are an affiliate of a parent nonprofit organization Proof previously . submitted and on_ file. with the. Gambling. Control Board. Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, lis tthe site where the drawing will take place) Church and.: Schpol•Buildings Address (do not use PO box) 380 Little Canada Road City Little Canada State/zip code Mn. 55117 County Ramsey Date(s) of activity (for raffles, indicate the date of the drawing) Sunday, October 24, 2004. Check the item(s) that Indicate tha type of gambling activity your organization will be conducting: XX "Bingo _ Raffles (cash prizes may not exceed $12,000) `Paddlewheels "Pull tabs _ "Tipboards 'Equipment for thaw activities must be obtained from a licensed distdbutoi, This form wit be made available in alternative format (Le. large print, Brallie)` upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, If you refuse to supply this Information, the Board may not be able to determine your quallficadons and, as a consequence, may refuse to issue you a penult. If you supply We information requested, the Board will be able to process your application. Your name and and your organization's name and address will be public information when received by the Board; All the other information that you provide will beprivate data about you until the • Board Issues your permit, When the Board issues your permit, all of the infomation that you have provided to the Baird In the process of applying for your permit will become public. If the Board doe; not Issue you a permit, ell the Information You have provided in the process of applying for a permit remains private, with the exception eptan of your name and your organization's name and address which will remain public. private data about you are available only to the following: Board members, staff of the Board whose work assignment requires that they have access m the information; the Minnesota Department of Public Safety; tha. Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other Individuals and agencies that are specifically authorized by state or federal law to have access to the information; Individuals and agencies for which law or legal order authorizes a new use or sharing of Information after this Notice was given; and anyone with your consent.