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YIVU Minnesota Lawful Gatnblin Page 1 of 2 06/03 LG220 Application for Exempt Permit Fee $50 Fee For Fee Only f Pa aidid Organization Information Cheek No. 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 Maine of chief executive officer (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 as above Daytime phone number of treasurer. Include area code Type of Nonprofit Organization Check the item that best describes your organization: _ Fratemal ix Religious _.._. Veteran __ Other nonprofit organization Check the item that indioetes 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 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, list the site where the drawing will take place) Church and..School+Buildings Address (do not use PO box) 380 Little Canada Road (thy Little Canada Stale /zip code Mn. 55117 County Ramsey Dates) of activity (for raffles, indicate the date of the drawing) Sunday, November 21, 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 *Pull•rabs "Tipboards 'Equipment for ih asp activities must be obtained from a licensed distributes, Thls form will be made available in alternative format (Le, large print, Braille) upon request, The inftsmadon requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to detannIne 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 qualifications and, as 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 address will be public information when received by the Board:° All the other inforrmaton tnatyou provide. will be private data about you'uncil the Board Issues your permit. When the Board Issues your permit, all of the Infoimatlon that you have provided to the Board in the process of applying for your permit will beconee public. If the Board doe;; not Issue you a pemtlt, ell the Information you have provided in the process of applying for a permit remains private, with therxrxption of your name and your organization's name and address which will remain public. Private data about you are available only to Me following: Board members, staff of the Boa rdwhose work assignment requires that they have access to the information; the Minnesota Department of Public Safety;;rhp• Minnesota Attorney General; the Minnesota Commissioners of Administrator, Finance, and Revenue; the Minnesota LegislativeAuditor, national and international gambling regulatory agendes; anyone pursuant to court order, other Individuals and agencies That are specifically authorized by state or federal law to have access Cottle 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.