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1.0220 <br />mew. ua'.3) <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 />OrgaNzatlon Name <br />Saint John's Church of Little Canada <br />Street City <br />380 Little Canada Road St. Paul <br />Chief ExeculNe Officer Daytime Phone Number <br />Rev. Robert Fitzpatrick ( 61)1 484 -2708 <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />CurrenttprevIous license number <br />State Zip code <br />Mn 55117 <br />Treasurer <br />same <br />CurrerWpmvlous exempt number <br />X-62005-95-.002 <br />County <br />Ramsey <br />Daytime Phone Number <br />( ) same <br />Type of Nonprofit Organization <br />Check the box below which indicates your type of organization <br />❑ Fraternal <br />❑ Veterans <br />ad Religious <br />❑ Other non -profit <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 />Gambling Site A member of St Paul /Mills Archdiocese'(on charter in your office) <br />Name of eke where adMy will take place <br />hoot gym <br />Street City Townshp <br />2621 McMenemy St. Paul Little Canada <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />November 19, 1995 <br />Types`of Games <br />Gamete) <br />State <br />MN <br />Zip code <br />55117 <br />County <br />Ramsey <br />Gross Receipts. <br />Financial Report <br />Fxpanses,lrrcluding <br />Net PrMHtt <br />Market Value of Prizes <br />(Including Donattona: <br />and cash) <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />5lsrrtautor from whom ganbiing.,equipmen was purchased.: <br />IAshbutoes license number:. <br />n <br />_aLt.4 .. ` �L,74? <br />I dada's all financial Information subndtted 20 the Ganlblltg:Conlrol <br />Board istruei accurate, and complete. <br />Ch. f ExecutIvs (Otac.re SI nnur Date Chef Exacutiv. Omc.rsSlgnaturi -. <br />Local Mitt of cavernment Acknouitedgment <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Board and will become effedive 30 days from the date of <br />receipt by the city or county, unless the local unit of government passes a resolution to specifically prohibit the adivity. A copy of that resolution must be received <br />by the Gambling Control Board within 30 days of the date filled In below. ales of the first lass have 60 days in which to disallow the adivity. <br />City or County <br />Township <br />Townshp name <br />Signature of person receMng application <br />Title 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. B, Suite 300 S. <br />Roseville, MN 55113 <br />Page 49 <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 />