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LG220 Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />(R•V.l1lluee) <br />FOR BOARD USE ONLY <br />FEE CNK <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 />Naive: and Address of Organization.:' <br />•rganlzaoon Name <br />St. John's Church of Little Canada <br />Street City <br />380 Little Canada Road St. Paul <br />Currenvprewous license number <br />Currenvprevwus exempt number <br />X- 67005 —R2 <br />County <br />Ramsey <br />State <br />Mn <br />Zip axle <br />55117 <br />Chief executiveofficer Phone Treasurer <br />Rev. Robert Fitzpatrick ( 612 ) 484 -2708 Tom Chapple <br />Phone <br />(612 )483 -2875 <br />Type of Nor-- profit Organization. <br />Check the box below which indicates your type of organization <br />❑ Fraternal in Religious ❑ Veterans ❑ Other non-profit <br />Gambling Site <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />❑ 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 />Name of site where activity will take place <br />in the school gym <br />Street City <br />2621 McMenemy St. Paul <br />Date(s) of activity <br />Township <br />State <br />MN <br />Zip code <br />55117 <br />County <br />Ramsey <br />October 27, 1991 <br />Game <br />Bingo? <br />Raffles ❑ <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs ❑ <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />rLc mplete. <br />C et e - utive Date <br />Local Gove " ent ricknorvtedgement <br />!'dt lotto ak ilWrgtatiod submiged <br />true, accurate• and •complete <br />•iffidiRrilb <br />PPS <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 spedfically 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 />Ctty or County <br />Township <br />City or coup clame <br />/L„Cnora <br />Signature,of per on receiving /application <br />Township name <br />Signature of person receiving application <br />Titled // ..Date received Title <br />E,;( <br />Date received <br />M1y_Bce Mail with $25 permit fee and Copy of proof of nonprofit status to: <br />tel <br />PM - - Q'ganineon Department of Gaming - Gambling Control Division <br />Yellow <br />tae JdI shad°agn°°°n to Rosewood Plaza South, 3rd Floor Page 5 <br />tamps xer <br />Ca10— 'gryaCaunry 1711 W. County Road 8 <br />Roseville. MN 55113 <br />