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Minnesota Lawful Gambling <br />Application for Exempt Permit - LG220 <br />Organization Information <br />For Board Use Only <br />Fee Paid <br />Check No. <br />Initials <br />Received /_/ <br />Organization name <br />St. John's of Little Canada <br />Previous lawful gambling exemption number <br />X- 62005 -98 -001 <br />Street City <br />380 Little Canada Road East St. Paul <br />State /Zip Code County <br />Minnesota 55117 Ramsey <br />Name of chief executive officer (CEO) of organization <br />First name Last name <br />Rev. Robert Fitzpatrick <br />Daytime phone number of <br />CEO: ( 651 ) 484 -2708 <br />Name of teasurer of organization <br />First name Last name <br />SAME <br />Daytime phone number of <br />treasurer. ( ) <br />Type of Nonprofit Organization <br />Check the box that best describes your organization: <br />❑ Fratemal <br />❑ Veteran <br />® Religious <br />❑ Other nonprofit organization <br />Check the box that indicates the type of proof your organization attached to this application: <br />❑ IRS letter indicating income tax exempt status <br />❑ Certificate of Good Standing from the Minnesota Secretary of State's Office <br />• A charter showing you are an affiliate of a parent nonprofit organization <br />❑ Proof previously submitted and on file with the Gambling Control Board <br />Gambling Premises Information <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />St. John's School gym <br />Address (do not use PO box) City State/Zip Code County <br />2621 McMenemy Street St. Paul Minnesota 55117 Ramsey <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />Sunday, October 25, 1998 <br />Check the box or boxes that indicate the type of gambling activity your organization will be conducting: <br />® *Bingo ❑ Raffles ❑ *Paddlewheels ❑ *Pull -Tabs ❑'Tipboards <br />*Equipment for these activities must be obtained from a licensed distributor. <br />This form will be made available in altemative format (i.e. large print, Braille) upon request. <br />The information requested on this form will become public information when received by the Board, and will be used to determine <br />your compliance with Minnesota statutes and rules goveming lawful gambling activities. <br />Page 1 of 2 <br />3/98 <br />Page 22 <br />