08-24-1994 Council Agenda - Laserfiche WebLink

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LG220 (Rev. (/2193) Minnesota Lawful Gambling Application for Authorization for Exemption from Lawful Gambling License Fill in the unshaded portions of this application for exemption and send it in at least 45 days before your gambling activity for processing. Name and Address of Organization FOR BOARD USE ONLY FEE CHK INIT DATE / / Organization Name St. John's of Little Canada Street City Slate Zip code 380 Little Canada Road Little Canada Mn 55117 Cunentprevlous license number Current/prevlous exempt number 67005- 94 —nn7 County Ramsey Chief Executive Officer Daytime Phone Number Rev. Robert Fitzpatrick (612)484 -2708 Type of Organization Treasurer same Daytime Phone Number ( ) Check the box below which indicates your type of organization ❑ Fraternal ❑ Veterans g Religious ❑ Other non -profit Gambling Site *A member of St. Paul /Mpls Name of site where activity will take place on the grounds and in the lower school Check the box that indicates your proof of nonprofit statue and attach a copy of the proof to the application. ❑ IRS designation ❑ Certification of good standing from the Minnesota Secretary of State's office Affiliate of parent nonprofit organization (charter) Archdiocese (on charter in your office) building Street City 380 Little Canada Read Date(s) of activity (for raffles, indicate the date of the drawing) Snndny, SPptombar 25, 19911 Types of Games Township Stale N .1.•. zip code County Game(s) Bingo Raffles 0 Paddlewheels ❑ Tipboards ❑ Pull -tabs I declare all information submitted to the Gambling Control Board is true, accurate, and complete. Financial Report Expenses, Including Cost of Prizes Net Profit Market Value of Prizes ;(Including Donations '. Distrbutor from whom gambling equipment was purchased Istibutors license number Ch l: Executiv Local Unit is ••rzuE15 re Vg/c4 ale ouernmentAcknowledgment I declare all financial information submated to. the Gambling Control::. Board Is true, accurate,: and complete. Chlef Executive Officers Signature Pate I have received a copy of this application. This application wik be reviewed by the Gambling Control Board and will become effective 30 days from the date of receipt 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 by the Gambling Control Board within 30 days of the date filled In below. Cities of the first class have 60 days In which to disallow the activity. City or County Township City of untynaame Signature I person recelvi itcatlon Title (J Township is Township name ❑ organized ❑ unorganized' Signature of person receiving application ❑ unincorporated* * Attach letter Date received iC- /O -95/ Title Date Received This form will be made available in alternative format (i.e. large print, braille) upon request. Mail with $25 permit fee and copy of proof of nonprofit status to: Gambling Control Board 1711 W. County Rd. B, Ste. 300 S. Roseville, MN 55113 Page 96 White - Original Yellow - Board returns to Organization to complete shaded areas