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LG220 <br />Rev06 /95 <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 />Initals <br />Date Recd <br />Organization Information <br />Organization Name Previous lawful gambling exemption number <br />Saint John's Church of Little Canada X- 62005096 -02 <br />Street City slate Zip Code County <br />380 Little Canada Road St. Paul Mn. 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 -2708 <br />Name of Organization Treasurer <br />First Name <br />SAME AS ABOVE <br />Last Name <br />Daytime Phone Number of Treasurer <br />( <br />Type of Nonprofit Organization <br />Check the box below which best describes <br />your organization <br />0 Fratemal <br />[� Veterans <br />mg Religious <br />No 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 />EyCertificate of good standing from the Minnesota Secretary <br />of State's office <br />ILA charter showing you're an affiliate of a parent <br />nonprofit organization <br />goof 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 />Saint John's School (Gym) <br />Street City State p Code County <br />2621 McMenemy St. aul Mn. 551 '/ Ramsey <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />Sunday, November 24, 1996 <br />Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br />it! Bingo 0 Raffles Paddlewheels L Pull -tabs Tipboards <br />Be sure the Local Unit of Government 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 />Page 104 <br />