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LG220 <br />(Rev.11 /14/901 <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 />Name and Addr of Organization' <br />Organization Name <br />Current/previous license number <br />St. John`s Church of Little Canada <br />Street Ciry State Zip code <br />380 E. Little Canada Road Little Canada Mn. 55117 <br />Current/previous exempt number <br />X- 62005 -82 <br />County <br />Ramsey <br />Chief executive officer Phone Treasurer <br />Rev. Robert Fitzpatrick( 612)484 -2708 Tom Chapple <br />Phone <br />(612 ) 483 -2875 <br />Type of Non.= profit Organization <br />Check the box below which indicates your type of organization <br />❑ Fraternal C* Religious ❑ Veterans ❑ Other non - profit <br />Gamblin • Site <br />Name of site where activity will take place <br />The Venetian Inn <br />Street City Township <br />2R14 MCP Street Tittle Canada <br />Date(s) of activity <br />Game <br />Bingo ❑ <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs ❑ <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 />! i k1 member of thYe St. ,Paul %Minneapolis <br />State <br />MN <br />Zip code <br />55113 <br />tosareeelpts;'. <br />Financial Report: <br />pensenk1nctuding Net profit <br />County <br />RnnS.ey <br />sr(cet Value <br />of Prizes:.:.... <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />mplete <br />Distributor from whom gambling equipment was purchased <br />Dm <br />tutor <br />lice <br />e number. <br />! cleclars all ytformatiorzsi,bmitted iot/ie <br />is true, accurate, and oomplet2 <br />xecutive o cer s s — Date <br />Lore 1;GOne • `r 0- nowtcdgement_ <br />CM'? <br />executive officer's <br />signature <br />Date <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Division and w'il 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 Township <br />City`r unity a e <br />Signatur of per rece ..pplication <br />-I__• __ , ,C- <br />bate received <br />Township name <br />Signature of person receiving application <br />White — Board <br />Pink ..— Organization <br />Yellow •'emrd returns to Organization to <br />complete shaded woos <br />Gold -- City or County <br />Mail with $25 permit t <br />Department <br />Ros <br />Title <br />Page 1 <br />Date received <br />f nonprofit status to: <br />trol Division <br />oor <br />