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LG220 <br />(Rev.11 /14/90) <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 d A ddr o"Organization <br />Organization Name - - - -- <br />St. John's Church of Little Canada <br />Street City State <br />380 Little Canada Road Little Canada Mn. <br />Chief executive officer Phone Treasurer <br />Rev. Robert Fitzpatrick ( 612) 484 -2708 <br />FOR BOARD USE ONLY <br />FEE <br />INIT <br />CHK <br />DATE <br />Current/previous license number <br />Current/previous exempt number <br />62005 -92 -004 <br />County <br />Ramsey <br />Phone <br />Zip code <br />55117 <br />same <br />tupoiofNortyrofitOrgantsattott <br />Check the box below which indicates your type of organization <br />❑ Fraternal LX Religious El Veterans ❑ Other non - profit <br />LiaMalilttj Sitt.; <br />Name of site where activity will take place <br />on the church grounds and in the lower school <br />Street City Township <br />9Rn T.itrj» Canada Road Little Canada <br />Date(s) of activity <br />Sunday September 26, 1993 <br />• <br />Game <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipbo <br />Pull -tabs <br />Attach proof of nonprofit status which shows <br />that your organization is nonprofit <br />O IRS designation <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />IN Affiliate of parent nonprofit organization (charter) <br />rrr•a'St (rin r'tx . .t itr yniar 1:Iff44A) <br />State <br />MN <br />Zip code <br />55117 <br />County <br />Ramsey <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and complete. <br />C-2 <br />Chi= executi e o c• s s e nature <br />1 -a -13 <br />Date <br />oval v merct IBC Ctioill�et gt'7ttent <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 govemment 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 />i ciedarti all mforM4tmo sObtritti <br />FS tfrte, acouratoiand coenple(e <br />Chi' executive <br />ce <br />signature <br />Rate <br />City or un amen <br />Signatur of per on receiv'- application <br />Tide <br />Township <br />Township name <br />Signature of person receiving application <br />to received <br />(57 --V-C3 <br />Title <br />Date received <br />WNW - eoerd <br />Pink - -Of gmhanon <br />Yet wv -Board reruns to OrganiaSon to <br />Compete shaded wets <br />Gold —.City or County <br />Mall with $25 permit fee and copy of proof of nonprofit status to: <br />Department of Gaming - Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Roseville. MN 55113 <br />Page 9 <br />