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LG220 <br />Mer.ttn.rao) <br />Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />Fill in the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing. <br />1V ame a ' d Address of organization <br />t$iyan nation Name Cunenvprewous license number Currenuprevious exempt number <br />St. John's Church of Little Canada <br />Street City <br />380 Little Canada Road St. Paul <br />Chief exewave officer <br />X- 62005 -82 <br />County <br />Phone <br />State <br />Mn. <br />Treasurer <br />Zip code <br />55117 <br />Ramsey <br />Rev. Robert Fitzpatrick ( 612)484 -2708 Tom Chapple <br />Type of Non-pr of t organization . <br />Phone <br />( 612) 483 -2875 <br />Check the box below which indicates your type of organization <br />❑ Fraternal a Religious ❑ Veterans ❑ Other non - profit <br />Gambling Site: <br />Name of site where activity will take place <br />in the school gym <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />O IRS designation <br />O Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />Street City <br />2621 McMenemy St. Paul <br />Date(s) of activity <br />November 241 1991 <br />Srjpescoxf <br />Game <br />Bingo L$ <br />Raffles ❑ <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs ❑ <br />Township <br />State <br />MN <br />Zip code <br />55117 <br />County <br />Ramsey <br />nanctal RepDrtl', <br />pensn,incttdrng Net:p oflt <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and complete. <br />ex env* Mc s s re Date <br />LocaL.Governmen • cknowledgement <br />Disitibuto <br />horn gambling diuipmeniwes pupa axed`.. <br />DistrtbutoYs license numbem <br />'1 ?chdawall information submittal to the Lamb <br />isjrue, accurate; andcomplete <br />Chief executive oiflcer's signature <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Division and will become effective 30 days <br />from the date of receipt by the city or county, unless the local government passes a resolu ion to specifically prohibit the activity. A copy of that <br />resolution must be received by the Gambling Control Division within 30 days of the date filled in below. Cities of the first class have 60 days in <br />which to disallow the activity. <br />City or County <br />Township <br />City or unty;name , <br />/ <br />Signature of person receiving application <br />CL -�c./ •.limo +iL ---'{,C— <br />Title/ /- / . .Date received <br />Township name <br />Signature of person receiving application <br />Title <br />Date received <br />Yn.e- Bard <br />RN-- dgen!iaem <br />Yellow - Beard,avna W 0.gonaban <br />temple°. shaded pees <br />Geld —. City or County <br />Mail with $25 permit fee and copy of proof of nonprofit status to: <br />Department of Gaming - Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road 8 Page 6 <br />Roseville. MN 55113 <br />