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LG220 Minnesota Lawful Gambling <br />rte " 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 />. rune and Mldress of Organization $, <br />Organization Name <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />St. John's Church of Little Canada <br />treat Ciry <br />Current/previous license number <br />State <br />Zip code <br />380 Little Canada Road St. Paul Mn. 55117 <br />Chief executive officer Phone Treasurer <br />Rev. Robert Fitzpatrick ( 612) 484 -2708 <br />same <br />Currenuprevious exempt number <br />62005 -92 -002 <br />County <br />Ramsey <br />Phone <br />( ) <br />ire of 'on profit Qrganiza ion <br />Attach proof of nonprofit status which shows <br />Check the box below which indicates your type of organization that your organization is nonprofit <br />❑ Fraternal M Religious ❑ Veterans ❑ Other non - profit ❑ IRS designation <br />❑ Certification of good standing from the Minnesota <br />Secretary of States office <br />ffAffiliate of parent nonprofit organization (charter) <br />a fir _ PS'ul /Mpt s ArrhdiAcnn <br />(on charter in your office) <br />("rtiilililinq ,Site <br />Name of site where activity will take place <br />school gym <br />Street City <br />2621 McMenemy St. Paul <br />Township <br />State <br />MN <br />Zip code <br />55117 <br />County <br />Ramsey <br />Dete(s) of achity <br />October 25, 1992 <br />esYf liflTlE'5.... <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull tabs <br />Ferlai <br />penses,tnctuding <br />a i ethrizae <br />dial Repot <br />Not profit <br />larket:Value <br />of Ptlzes <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />omplete. <br />Ch <br />u <br />execut <br />alt u fo mono r wbrnrtted lo:tt <br />ctuata, and compinfe <br />1E1 <br />.ntr t <br />nature Date <br />Local u i �P t Acknowledgerttent <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 />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 />City or y tin / ame <br />-t <br />gnature�6f pe, on red:;, n ,application <br />Township <br />Township name <br />Date received <br />White — Board <br />Pink — — Organization <br />Yellow ..Board reruns to Organization to <br />mmplole shaded wads <br />Gold City or County <br />Mail with $25 p <br />Dept <br />Signature of person receiving application <br />Title <br />Page 1 <br />Date received <br />fit status to: <br />n <br />