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L0220 Minnesota Lau/ful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />(Itw.itn490) <br />FOR BOARD USE ONLY <br />FEE <br />INIT <br />CHK <br />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 />Name and Addiress of Organization <br />(Srganitaoon Name <br />St. John's Church of Little Canada <br />Currenvprewous license number <br />creel <br />380 E. Little Canada Road St. Paul <br />Chief executive officer Phone <br />Rev. Robert J. Fitzpatrick ) <br />I9 <br />Mn <br />Treasurer <br />(612) 484 -2708 <br />p <br />code <br />55117 <br />Tom Chapple <br />Type of Non-pprofit Organization <br />Current/previous exempt number <br />X- 62005 -82 <br />County <br />Ramsey <br />Phone <br />(612) 483 -2875 <br />Check the box below which indicates your type of organization <br />❑ Fraternal () Religious ❑ Veterans ❑ Other non - profit <br />Gambling Site: <br />Name of site where activity will take place <br />•. •- <br />Street - City <br />380 Little CAnada Road <br />Date(s) of activity <br />September 29, 1991 <br />'hypes of Games <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />❑ IRS designation <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />❑ Affiliate of parent nonprofit organization (charter) <br />• <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />Township - Ol. State <br />e <br />Zip code <br />St Paul (Little CAnada) l" 55117 <br />County <br />Ramsey <br />raeaiptt <br />fetuasd inciuE(ri <br />Cost oE:Prtzee i <br />nanculr: Report <br />:, <br />}"arks! Vatta. <br />:6f:Prizae•�I <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />omplete. <br />4.411 1/Zigi <br />C t ex • utive '3 sWieture Date <br />Local Gone ent Acknowledgement <br />•prstriburorfrorn whom gariiaing equipment <br />putchased' <br />Dustrtbutor :.license number: <br />1 I'doclareaM r+lonnadorrsubtnrttedto the Gambxng C.p. ntrol: <br />is pus, accuraia and complete ... `... • <br />Chit, executive officer's signature <br />•Date }: <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 resolution to specifically prohib't 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 />Ciry or,couunLttyy/name <br />L. <br />Signature of person reaeiving application <br />Township name <br />Signature of person receiving application <br />Titl ; i Date received <br />i:�i:';•C i -rj- <br />4 -' — ' / <br />vmu -Board <br />Prk- _dgmaaum <br />Ywor -Boma returns Q'9aV U.on to <br />compete Shaded aea <br />Gold —. City a County <br />Title <br />Date received <br />Mail with $25 permit fee and copy 0f proof of nonprofit status to: <br />Department of Gaming - Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B 4 <br />Roseville. MN 55113 page <br />