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L0220 Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />(Rev.11 /141501 <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 attd ac Qf Organi}zaxian <br />Organization Name <br />St. John's Church of Little Canada <br />Current/previous license number <br />Current/previous exempt number <br />62005 -92 -002 <br />Street City <br />380 Little Canada Rd. <br />Chief executive officer <br />St. Paul <br />Phone <br />Rev. Robert Fitzpatrick 612) 484 -2708 <br />State Zip code <br />Mn. 55117 <br />Treasurer <br />same <br />County <br />Ramsey <br />Phone <br />�e a, f art p rofit Organization <br />Check the box below which indicates your type of organization <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />❑ Fraternal CReligious ❑ Veterans ❑ Other non - profit ❑ IRS designation <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />x1 Affiliate of parent nonprofit organization (charter) <br />S of the St. Yau7-!Napls. &Xt.'lialwcese .... <br />(on charter in your office) <br />Garnbinc�i Site <br />Name of site where activity will take place <br />school gym <br />Street <br />City <br />2621 McMenemy St. Paul <br />Date(s) of acovity <br />Hpy mheC.77, <br />Type o Gailtps: <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />Township <br />State <br />MN <br />Zip code <br />55117 <br />County <br />Ramsey <br />atket:Valusi <br />..................... <br />fe6:Rri3a'ei::iz <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />omplete. <br />Chief .xecut SO 'ers signature <br />Local Go; mertt Ackft: utedgeme t <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,•um. nam: <br />/ /_e ems <br />Signatu <br />Township <br />Township name <br />of p on red vi g application <br />Title„ / U Date received <br />dcta/. 9ov -f <br />Signature of person receiving application <br />White — Board <br />Pink — — Organization <br />Yellow --Board rattans to Organization to <br />complete shaded woes <br />Gold •. —Cy or County <br />Mail with $25 permit <br />Departmen <br />Re <br />Title <br />Page 2 <br />Date received <br />nonprofit status to: <br />of Division <br />;or <br />