09-27-1995 Council Agenda - Laserfiche WebLink

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LG420 (Roe. 4/2/03) Minnesota Lawful Gambling Application for Authorization for Exemption from Lawful Gambling License All in the unshaded portions of this application for exemption and send if in at least 45 days before your gambling acdviry for processing. Name and Address of Organization Organization Name Saint John's Church of Little Canada shoei City 380 Little Canada Road St. Paul CNeI Executive Officer Daytime Phone Number Rev. Robert Fitzpatrick (612) 484 -2708 tithe o son profit Organization FOR BOARD USE ONLY FEE CHK INIT DATE Currendprevlous license number Current/previous exempt number X- 62005 -95 -002 State Mn. Treasurer zp code 55117 same County Ramsey Daytime Phone Number ( ) same Check the box below which indicates your type of organization ❑ Fraternal ❑ Veterans aj Religious ❑ Other non -profit • Gambling Site memberzof St. Paul /Mills Archdiocese ('nn charter in your office) Name of axe where aaMy will take place school gym Check the box that indicates your proof of nonprofit status and attach a copy of the proof to the application. ❑ IRS designation ❑ Certification of good standing from the Minnesota Secretary of State's office a Affiliate of parent nonprofit organization (charter) Street City Township 2621 McMenemy State St. Paul Little Canada MN Zip code 55117 County Ramsey Dath(s) of activity (for raffles, kxxcale the date of the drawing) Sunday, October 29, 1995 Types ofGames Gams(s) Bingo Raffles Paddlewheels ❑ Tipboards ❑ Pull -tabs ❑ l declare all information submitted to the Gambling Control Board is true, accurate, and complete. :Gross Receipts Financial Report•. Expanses, Including . Cost'of.Prizn Net Profit{ 7lstrbutor Iron whom gambling equipment was purchased Merlat.Value of Prizes (Including Donations :arid cash) �f 2 Chief Ex uttvs 0 ors Ig bats Loc Unit of t Acknowledgment I have received a copy of this application. This application will be reviewed by the Gambling Control Board and will become eaedive 30 days from the date of recap' by the city or county, unless the focal unit of goverment passes a resolution to specifically prohibit the achy. A copy of that resolution must be received by the Gambling Control Board within 30 days of the date filled In below. ClIes of the first dass have 60 days In which to disallow II* activity. City or county s IJ tutor's license number declare all tinandat inionnatbn submitted to the Gambling Control:.. Board Mirue, accurate, andtomplate. Chief Executive Officer's Signature Township Ctyor unty Signature of rson calving n Tit le Ie D received / Ante— This form will be made available in alternative format (i.e. large print, braille) upon request. Township name Signature of person receiving application Tfte Mail with $25 permit fee and copy of proof of nonprofit status to: Gambling Control Board 1711 W. County Rd. B, Suite 300 S. Roseville, MN 55113 Page 48 Township is ❑ organized ❑ unorganized' ❑ unincorporated* Attach letter Date Received White - Original Yellow - Board returns to organization to complete shaded areas