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LG220 <br />Rev06l95 <br />Minnesota Lawful Gambling <br />Application for Authorization for an <br />Exemption from Lawful Gambling License <br />For Board Use Only <br />Fee Paid <br />Check # <br />Initais <br />Date Recd <br />Organization Information <br />Organization Name <br />St. John's of Little Canada <br />Previous lawful gambling exemption number <br />X 62005 -96 -001 <br />Street City S <br />380 Little Canada Road St. Paul Mn <br />ate Zip Code County <br />55117 Ramsey <br />Name of Chief Executive Officer <br />First Name <br />Rev. Robert <br />of organization (CEO) <br />Last Name <br />Fitzpatrick <br />Daytime Phone number of CEO <br />,612 484 -2703 <br />Name of Organization Treasu <br />First Name <br />SAME AS ABOVE <br />er <br />Last Name <br />Daytime Phone Number of Treasurer <br />Type of Nonprofit Organization <br />Check the box below which best describes <br />your organization <br />0 Fratemal <br />0 Veterans <br />[n Religious <br />Other nonprofit <br />Check the box that indicates the type of proof attached to this application <br />by your organization: <br />IRS letter indicating income tax exempt status <br />Epertificate of good standing from the Minnesota Secretary <br />of State's office <br />IIE/A charter showing you're an affiliate of a parent <br />nonprofit organization <br />proof previously submitted and on file with the Gambling Control <br />Board <br />Gambling Premises information <br />Name of Establishment where gambling activity will be conducted <br />St. John's Church and School (buildings and grounds) <br />Street City State Zip Code County <br />380 E. Little Canada Road St. Paul Mn. 55117 Ramsey <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />Sunday, September 29, 1996 <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br />r Bingo [n Raffles El Paddlewheels 293 Pull -tabs Tipboards <br />Be sure the Local Unit of Govemment and the CEO of your organization sign <br />the reverse side of this application. <br />For Board Use Only <br />Date & Initials of Specialist <br />