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Lt•720 <br />(Flee. 412113) <br />Minnesota Lawful Gambling <br />Application for Authorization for <br />Exemption from Lawful Gambling License <br />Fill in the unshaded pasticris 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 />lCunenVlxevbus license number <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />/ <br />Currerxtrevbus exempt nutter <br />62005 -94 -003 <br />Street City <br />380 Little Canada Road St. Paul <br />CNN Executive Coker Dwaine Ptoos Nunt.r <br />Rev. Robert Fitzpatrick 612 ) 484 -2708 <br />Type of Non - profit Organization <br />State <br />Mn. <br />Zb code <br />55117 <br />Treasurer <br />same <br />County <br />Ramsey <br />CayMne Phone Nunter <br />( ) same <br />Cheek the box below which indicates your type of organization <br />❑ Fraternal <br />❑ Veterans <br />fa Religious <br />❑ Other non -profit <br />.Gambling Site A member of St. <br />Name of site where activity win lake puce <br />school gym <br />Check the box that indicates your proof of nonprofit <br />status and attach a copy of the proof to the application. <br />G1 IRS designation <br />0 Certification of good standing from the Minnesota <br />Secretary of State's office <br />a Affiliate of parent nonprofit organization (charter) <br />Paul /Mills Archdiocese (on charter in your office) <br />street <br />2621 McMenemy <br />Little Canadapwmstp <br />State <br />MN <br />5511711 <br />County <br />Ramsey <br />Date(s) of activtty (for rattles, indicate the date of the drawing) <br />Sunday, October 30, 1994 <br />Types of Games <br />Game(*) <br />Gives Receipts <br />Financial Report <br />Expenses, Including <br />Costal Prima <br />NM Prom <br />Market Valle" of Prime <br />(Including Donation* <br />and =am <br />Bingo <br />Raffles <br />Paddlewheels <br />Tipboards <br />Pull -tabs <br />1 declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />aksumeor earn venom gr,cr g «aromen ..s pualsa.d <br />1101101160 1•0•0111 <br />� p <br />ChSf Ex 5 . urn o.. <br />NT r. at SOWS w.rer.n.1 r r•••*• •• a G. — CASA <br />11•11••► M 111•11•.r111111. <br />Local U •e• . • ent Acknowledgment <br />prof Exwaen Casten E•.•errr. <br />One <br />I have tecerved a copy at this appera1bn. This appndtlbn was to renewed by ms awing Contra Board and IDS Downs adios XI den *da re ewe r <br />receipt by the cty or county, union the Io at unit 01 covermlart passes a resoUtlon to weancW pruned trio raPay. A copy a tt.a r.eo*Aen asst be wow11d <br />by the Gambling Control Board wtNn 30 days oI the dale tilted In below. Gale at dM IM class rune 60 days n anon to lW +ms •ally <br />Tovmshtp is <br />organized <br />0 unorganized' <br />0 unincorporated' <br />Attach letter <br />City or County <br />iownsMP <br />City of uray name <br />d <br />Signature ql nelson oennng .. .lap <br />Tea <br />d. 7,,t . <br />This form will be made available <br />in attemative format (i.e. large <br />print, braille) upon request. <br />Townsno name <br />Signature a person recemng app•catrcn <br />• <br />carved <br />TW <br />CUM Rscslved <br />Mail with 525 permit fee and copy of <br />proof of nonprofit status to: <br />Gambling Control Board <br />1711 W. County Rd. 8, Ste. 300 S. <br />Roseville, MN 55113 <br />PAGE 1 <br />White - Original <br />Yellow - Board retums to <br />Organization to complete <br />shaded areas <br />