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LG220 <br />(Rev.i fnd,9e) <br />Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <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 turd Add.Y e ss of 7rgani atinri <br />Organization Name <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />St. John's Church of Little Canada <br />Street City <br />St. Paul <br />Phone <br />Rev. Robert J. Fitzpatrikk ) 612 484 -2708 <br />380 Little Canada Road <br />Chief executive officer <br />number <br />Current/previous license mber ber <br />State <br />Mn. <br />Treasurer <br />Zip code <br />55117 <br />same <br />Currenuprevious exempt number <br />X- 62005 -82 <br />Ramsey <br />Phone <br />County <br />Type of Nonprofit Organizatl%ar <br />Check the box below which indicates your type of organization <br />❑ Fraternal g Religious ❑ Veterans ❑ Other <br />*OM iriireg SA.t <br />Name of site where activity will take place <br />in the school <br />Street <br />City <br />2621 McMenemy St. Paul <br />Date(s) of activity <br />Saturday, May 30, 1992 <br />of Games, <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />non - profit <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 />X7 Affiliate of parent nonprofit organization (charter) <br />A mevher pf.the Ste Paulftip$5. Archdiocese <br />(on charter in your office) <br />Township <br />State <br />MN <br />EYpenseat including <br />Cnsl et Prizes <br />Zip code <br />55117 <br />County <br />Ramsey <br />I declare all information submitted to the <br />Gambling Control 9' ision is true, accurate, <br />• • complete. <br />l doc/are all +nferr.ation submitted fo the Gamb>rng Control <br />s true, accurate, and completet ... .. _... <br />executiv <br />attire Date <br />1 =aI Gn ern eat Aekttentledgement <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 prohibit the activity. A copy of that <br />which to disallow the actiresolution 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 />vity. <br />City or County Township <br />Chief •executlye efficer's signature <br />Date <br />City or my Township name <br />Sian _fur: •f per <br />J <br />ece )vin <br />on <br />72� <br />Tit) <br />artCe'1466.1 f- - <br />white -Board <br />Pink -- Orgmiz(Mon <br />Ye/low -Booed ,euens to OrgonazatIon to <br />wnpo,e shaded woos <br />Gold --Oily or Canty <br />Date 46ceived <br />� -tea <br />Mail with $25 permit fee and copy of proof of nonprofit statues to: <br />Department of Gaming - Gambling Control Division rage 7 <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Signature of person receiving application <br />Title <br />Date received <br />