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LG220 <br />(Rev. 4m90) <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 aril Address of Organization: <br />Current/previous license number <br />FOR BOARD USE ONLY <br />FEE CHK <br />INIT DATE <br />Organization Name <br />St. John's of Little Canada <br />Street City <br />380 Little Canada Road St. Paul <br />ONO ExecutNe Officer Daytime Phone Number <br />Rev. Robert 'Fitzpatrick (612)484 -2708 <br />Tgpe ofwon profit Organization <br />Cuneni/prevbus exempt number <br />X 62005 -94 -005 <br />State Z4 code <br />55117 <br />Treasurer <br />same <br />County <br />Ramsey <br />Daytime Phone Number <br />( ) same <br />Check the box below which indicates your type of organization <br />❑ Fraternal <br />❑ Veterans <br />5thX Religious <br />❑ Other non -profit <br />Gambling site ! <br />Name of site where activity MI take place <br />on the grounds and in the lower <br />Check the box that indicates your proof of nonprofit <br />status and attach a copy of the proof to the application. <br />❑ insdesignation <br />❑ Certification of good standing from the Minnesota <br />Secretary of State's office <br />la Affiliate of parent nonprofit organization (charter) <br />school building <br />Street City Township <br />380 Little Canada Road Little Canada <br />Date(s) of adNity (nor rallies, indicate the date of the drawing) <br />Sunday, September 24, 1995 <br />Tgpes`of Games <br />Bingo <br />Rama(s) <br />�tl <br />Stale <br />MN <br />551o1od7e <br />County <br />Ramsey <br />Gnus Receipts <br />Financial Report <br />HetProfit. <br />MarketValus otPrizes <br />(Including Donations <br />. and cash) <br />lipboards <br />Pull -tabs <br />I declare all information submitted to the <br />Gambling Control Board is true, accurate, <br />and complete. <br />Distrbutortromwhom ga frog equipment was purchased <br />Uisubuto's license number <br />i declare ail financial Intorrnatbn submitted to the Gam ting.Control'.. <br />Board islrue aaurale, and complete. <br />Chief Executive Ofncses Signature Date <br />Cbbf Executive Offcar's Signature <br />Local Unit of Acknowledgment <br />I have received a copy of this application. This application will be reviewed by the Gambling Control Board and will become effective 30 days from the date of <br />receipt by the city or county, unless the local unit of government passes a resolution to spedlbaty prohibit the activity. A copy of that resolution must be received <br />by the Gambling Control Board within 30 days of the date lilted In below. Cities of the first Bass have 60 days in which to disallow the activity. <br />Township is <br />❑ organized <br />❑ unorganized' <br />❑ unincorporated* <br />Attach letter <br />city or County <br />Township <br />City or county name <br />Township name <br />Signature of person receiving application <br />Signature of person receiving application <br />Tale <br />Date received <br />Title <br />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 39 <br />White - Original <br />Yellow - Board returns to <br />organization to complete <br />shaded areas <br />