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LG220 Minnesota Lawful Gambling <br />Application for Exemption from <br />Lawful Gambling License <br />(Rev.it /14/90) <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 />1mm mttd ArldrSs of Orgatitzatiort <br />Organization Name <br />St. John's Church of Ttittle,Canada <br />Street City <br />380 Little Canada Road St. Paul <br />Chief executive officer Phone <br />Rev. Robert Fitzpatrick (612) 484 -2708 <br />Currentlprevious license number <br />........... ....... . <br />'Current/previous exempt number <br />State <br />Mn <br />Treasurer <br />Zip code <br />55117 <br />same <br />62009 -91 -007 <br />County <br />Ramsey <br />Phone <br />Type ofNon profit Urgartizat;art <br />Check the box below which indicates your type of organization <br />❑ Fraternal 1 CReligious ❑ Veterans ❑ Other non - profit <br />Goth lx tg :$LtG' °: Ct tttiszul7er <br />Name of site where activity will take place <br />school gym <br />Pain <br />%Mvls tAre <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 />a Affiliate of parent nonprofit organization (charter) <br />lease (Ox),; #Cha'rt<+ur ±n your." off- tree)` <br />Street City <br />2621 McMenemy Street St. Paul <br />Date(s) of activity <br />Sunday= October s 24 1993 <br />jpes U Game <br />Township <br />Game <br />Bingo <br />State <br />MN <br />Zip code <br />55117 <br />County <br />Ramsey <br />rrz,lcto <br />........................ <br />es,inciudin <br />'nit?rivea::':: <br />Raffles ❑ <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs <br />I declare all information submitted to the <br />Gambling Control Division is true, accurate, <br />and complete. <br />of executive office si nat re Date <br />;Local Goverrtrtrert Actertocl>iedgemen <br />pi ttsburor from who <br />mtillng equipments? <br />pistrtbUt V. ;ff.cense numb/ff.i <br />actara alt informason subMitfed <br />true, accurate, and ccrnpleto, <br />Chief executiv <br />ambling <br />of <br />ffioers signature <br />pi <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 Township <br />City or county name <br />Township name <br />Signature of person receiving application <br />Signature of person receiving application <br />Title <br />Date received <br />Title <br />Date received <br />while — Board <br />Pink — — Orgenixatlm <br />Yellow —Board returns to O gor zaeon 10 <br />complete shaded areas <br />Gold.... City or County <br />Mail 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 51 <br />