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LG220 <br />(Rev. 4/203) <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 />Organization Name <br />St. John's Church of Little Canada <br />Street City State Zp code <br />380 Little Canada Road St. Paul Mn 55117 <br />Chet Executive allcer Daytime Phone Number Treasurer <br />Rev. Robert Fitzpatrick ( 61i 484 -2708 <br />Type of Non profit Organization <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />Current/previous license number <br />same <br />Current/prevlous 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 />a Religious <br />❑ Other non -profit <br />Gambling Site ' A member of the St. <br />Name of site where adlvity will take place <br />in the school gym <br />Street City McMenemy c St. Paul <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 standing from the Minnesota <br />Secretary of State's office <br />® Affiliate of parent nonprofit organization (charter) <br />Paul /Mpls_Archdiocese (on chaiter in your offiee) <br />ownship State Zp code <br />Little Canada MN 55117 <br />County <br />Ramsey <br />Date(s) of activity (for raffles, kd lcale the date of the drawing) <br />February 13, 1994 <br />Types of Games <br />Bingo <br />Game(s) ;::.Gross Receipts <br />Financial Report <br />Expenses, including <br />° Cost of Prizes <br />Net Profit: <br />Raffles ❑ <br />Market Value of Prizes <br />(Inciuding n <br />and casDoh) ation. <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull- tabs Di <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />Distrbutor from whom gambling equipment was purchased. <br />Distributors license number <br />1 dedare all financial information submitted to the Gambling Control. <br />Board Is true, accurate, and complete. <br />vernment Acknowledgment <br />Chief Executive Officers Signature Date <br />I have received a copy of this application. This application wit be reviewed by the Gambling Control Board and will become effective 30 days from the date of <br />recept by the city or county, unless the local unit of government 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 filled In below. Cities of the first lass have 60 days In which to disallow the activity. <br />City or County <br />CI of <br />Township <br />my <br />Sig lure •t pers receivirg'application <br />u Date received <br />Township name <br />Signature of person receiving application <br />Ttlo <br />Date Received <br />This form will be made available <br />in alternative format (i.e. large <br />print, braille) upon request. <br />Mail with $25 permit fee and copy of <br />proof of nonprofit status to: <br />Gambling Control Board <br />1711 W. County Rd. 6, Ste. 300 S. <br />Roseville, MN 55113 <br />Page 18 <br />Township is <br />❑ organized <br />❑ unorganized' <br />❑ unincorporated' <br />* Attach letter <br />White - Original <br />Yellow - Board returns to <br />Organization to complete <br />shaded areas <br />