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Minnesota Charitable Gambling Control Board <br />Room N475 Griggs - Midway Building <br />1821 University Avenue <br />St. Paul, MN 55104 -3383 <br />(612) 642 -0555 <br />LAWFUL GAMBLING EXEMPTION <br />FOR BOARD USE ONLY <br />INSTRUCTIONS: 1. Submit request for exemption at least 30 days prior to the occasion. <br />2. When completing form, do not complete shaded areas. <br />3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will be <br />returned with an exemption number added to the form. When your activity is concluded; complete the <br />PLEASE TYPE financial information, sign and date the form, and return to the Board within 30 days. <br />Organization Name <br />St. John's Church of Little Canada <br />LGM• ?&,nbe In MMIN or ceeaaa'lr licensed) <br />A- 00559 -01 <br />Address <br />380 E. Little Canada Road <br />City, County. State. Zip Code <br />Little Canada, Mn. 55117 <br />Chief Executive Officer's Name <br />Rev Roherr Fir7parrick <br />Phone Number <br />484 -2708 <br />Manager's Name <br />Thomas Chapple <br />11 Other Nonprofit Organization (Check One) <br />❑ IRS Designation <br />❑ Incorporated with Secretary of State <br />❑ Affiliate of Parent Nonprofit Organization <br />Phone Number <br />483 -2875 <br />Type of Organization <br />❑ Fraternal ❑ Veterans <br />a Religion ❑ Other Nonprofit Organization <br />Name of Premises Where Activity Will Occur <br />on grounds and in lower church and school <br />Datets) of Activity <br />August 1, <br />1987] <br />Premises Address <br />380 East Little Canada Road <br />Games <br />Yes <br />No <br />Gross Receipts <br />Value of Prizes <br />Expenses <br />Profit <br />Bingo <br />X <br />Raffles <br />X <br />Paddlewheels <br />X <br />Tipboards <br />X <br />Pull -Tabs <br />X <br />Use of Profit <br />Distributor From Whom Gambling Equipment Acquired <br />Distributor's License No. <br />I affirm all information submitted to the Board is true, accu- <br />Alr <br />b <br />Chief xecut e Officer <br />rate <br />complete. <br />Date <br />1 affirm all financial information submitted to the Board is <br />true, accurate, and complete. <br />Chief Executive Officer Signature <br />Date <br />ACKNOWLEDGMENT OF NOTICE BY LOCAL GOVERNING BODY <br />I hereby acknowledge receipt of a copy of this application. By acknowledging receipt, I admit having been served with notice <br />that this application will be reviewed by the Charitable Gambling Control Board and will become effective 30 days from the <br />date of receipt (noted below) by the City or County, unless a resolution of the local governing body is passed which specifi- <br />cally disallows such activity and a copy of that resolution is received by the Charitable Gambling Control Board within 30 <br />days of the below noted date. <br />CITY OR COUNTY TOWNSHIP <br />Name of Local Governing Body ICity or County) <br />City of Little Canada <br />Township Name (Must be notified when County 15 the aporovtng body, <br />Ognatu of Person Re7 Applicant) <br />City Clerk <br />Signature of Person Receiving Application <br />6/22/87 <br />Date Received <br />Title Dare <br />CG 00020.01 14,261 <br />White - Board Canary - Board returns to Organization to keep <br />Pink - Otgan,zation Gold - City or County <br />4 <br />