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LG220 <br />(Pas. sawn <br />Minnesota Lawful Gambling <br />Application for Authorization for <br />Exemption from Lawful Gambling License <br />Pill in the unshaded portions ot this application for exemption and <br />send R in at least 45 days before your gambling activity for processing. <br />Name and .Address-of organization <br />Oryertiauon Name ( CurtenMWevbus license number <br />St. John's Church of Little Canada <br />Street 380 Little Canada Roca/ St. Paul statfin zb`ccie 55117 <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />/ / <br />CunerWivlous exempt number <br />62005 -94 -003 <br />County Ramsey <br />CtsM Executive Grocer Daytime Phone Number Tnawrer Daytime Phone Number <br />Rev Robert Fitzpatrick €012) 484 -2708 same ( ) <br />Type of Non-profit Organization. <br />Check the box that indicates your proof of nonprofit <br />Check the box below which indicates your type of organization status and attach a copy of the proof to the application. <br />❑ <br />Fraternal ❑ IRS designation <br />❑ Veterans ❑ Certification of good standing from the Minnesota <br />a Religious Secretary of Stata's office <br />❑ Other non -profit al Arians of paint nonprofit organization (charter) <br />Gmnbling Site: 'A member of'St'..'Pauh /Mpls. Archdiocese (on charter. in 'your office) <br />Name of see where aaMty will take place <br />school gym <br />Sheet Cay Towns <br />2621 McMenemy Little Canada <br />State <br />IAN <br />5117 <br />County <br />Ramsey <br />D•t•(s) of activity (tor ratites, Indicate the date 04 the &awl g) <br />Sunday, November 20, 1994 <br />Types of Games <br />Games) <br />Gross Receipts <br />Financial Report <br />Expanses, Including <br />Cost of Nixes <br />Not Profit' <br />Market Value of Prizes <br />(Including Donations <br />WW1 cash) <br />Bingo <br />Raffles <br />Paddlewheels ❑ <br />Tipboards ❑ <br />Pull -tabs ❑ <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />}istrt nor from wtwm ganolkg equipment was purchased. <br />It u4 l license number <br />Executive <br />Local Unit <br />I aware au financial INonnation submitted to the. Gambling Contra <br />Board is true, accurate. and complete. <br />t Acknowledgment. <br />PUN Executive GMcer's- ignatur• Date. <br />I hive mend a copy a this application. This appIcatton via be reviewed by the Gambling Control Board and will become onerous 30 days from tra rata a <br />racyn by the city or county, unless the local unit ot government passes a resolution to vocalically proNbl the adMy_ A copy a that restitution must be received <br />by Ms Gambling Contra Board within 30 days of the date fled In below. Ctles a the IM class have 60 days In wroth to disallow the activity. <br />City or Conroy <br />Township <br />City county name <br />Skew <br />v <br />/ • ed <br />or 94/ <br />Township name <br />Signature of person receiving appucallon <br />The Dale Received <br />This fomt 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. B. Suite 300 S. <br />Roseville, MN 55113 <br />PAGE 2 <br />Township is <br />❑ organized <br />❑ unorganized' <br />❑ unincorporated' <br />`Attach letter <br />White - Original <br />Yellow - Board retums to <br />organization to complete <br />shaded areas <br />