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LG220 <br />(Rev, 4/2193) <br />Minnesota Lawful Gambling <br />Application for Authorization for <br />Exemption from Lawful Gambling License <br />Fill in the unshaded portions of this application for exemption and <br />send it in at least 45 days before your gambling activity for processing. <br />Name and Address of organization <br />Otganlzatlon Name <br />St. John's Church of Little Canada <br />Street City <br />380 Little Canada Road St. Paul <br />Chief Executive Officer <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />Current/prevbus license number <br />Daytime Phone Number <br />Rev. Robert Fitzpatrick (613 484 -2708 <br />Type;' of Non-profit Organization <br />State zip code <br />Mn. 55117 <br />Treasurer <br />same <br />CurrenVpreWous exenpt number <br />' 62005 -93 -004 <br />County <br />Ramsey <br />Daytime Phone Number <br />Check the box below which indicates your type of organization <br />❑ Fmtemal <br />❑ Veterans <br />DI Religious <br />❑ Other non -profit <br />Gambling Site A menthe <br />Name of site where activity will take place <br />The Venetian Inn <br />Street City Township <br />2814 Rice Street St. Paul Little Canada <br />betels) of activity (for rattles, indicate the date of the drawing) <br />February 5 1994 <br />Check the box that indicates your proof of nonprofit <br />status and attach a copy of the proof to the application. <br />❑ IRS designation <br />❑ Certification of good stancing from the Minnesota <br />Secretary of State's office <br />® Affiliate of parent nonprofit organization (chatter) <br />of the St. `Paul /Mpls. Archdiocese (on charter in your office) <br />Types of Games <br />State <br />MN <br />Zp code <br />55117 <br />County <br />Ramsey <br />Game(s) <br />Bingo <br />Raffles <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs <br />Gross Receipts <br />Financial, Report <br />Expenses, Including <br />Cost of Prizes <br />Nat Profit' <br />Market Value. of Prizes <br />(Including Donations <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />list tutor from whom garbling equipment <br />Dlsbbutors license number <br />as purchased <br />Executiv ota rs $ <br />Local Uni • ov <br />�. <br />3:3 <br />declare all financial Information submitted to the Gambling Control <br />Board Is tare, accurate, and complete. <br />Date <br />pis - <br />Date <br />ent.Acknowledgment <br />Chief Executive Officers Signature -`Date <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Board and will become effective 30 days from the date of <br />receipt by the city or county, unless the local unit of govemnsnt passes a resolution to specifically prohibit the activity. A copy of that resolution must be received <br />by the Gambling Control Board within 30 days of the date flUed In below. Cities of the first lass have 60 days In which to disallow the activity. <br />City or County <br />Township <br />City of <br />Slgne ureyi person icawing <br />n <br />Township name <br />Dale'rewived <br />Signature of person receiving application <br />Title <br />,62--/5-13 <br />Date Received <br />This form will be made available Mail with $25 permit fee and copy of <br />in alternative format (i.e. large proof of nonprofit status to: <br />print, braille) upon request. Gambling Control Board <br />1711 W. County Rd. 8, Ste. 300 S. <br />Roseville, MN 55113 <br />Page 17 <br />Township is <br />❑ organized <br />❑ <br />unorganized* <br />❑ unincorporated' <br />Attach letter <br />White - Original <br />Yellow - Board returns to <br />Organization to complete <br />shaded areas <br />