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Re os�s Minnesota Lawful Gambling For Board Use Only <br /> Fee Paid <br /> Application for Authorization for an <br /> Check # <br /> ,Exemption from Lawful Gambling License <br /> Initals <br /> Date Recd <br /> Organization Information' <br /> Organization Name Previous- iawfui gambling exemption number <br /> Church of St. Genevieve X g,`Gbg7 <br /> Street City State Zip Code County <br /> 7087 Goiffon Road, Centerville MN 55038 Anoka <br /> Name of Chief Executive Officer of organization (CEO) Daytime Phone number of CEO <br /> First Name Last Name <br /> Rev. Richard J. Wolter (614 429 -7937 <br /> N ame of Organization Treasurer Daytime Phone Number of Treasurer <br /> First Name Last Name y <br /> Diane Kieffer (612) 429 -5069 <br /> Type of Nonprofit Organization <br /> Check the box below which best describes Check the box that indicates the type of proof attached to this application <br /> your organization by your organization: <br /> IRS letter indicating income tax exempt status <br /> � Fraternal <br /> Veterans Certificate of good standing from the Minnesota Secretary of State's office <br /> � <br /> ® Religious 0 A charter showing you're an affiliate of a parent nonprofit organization <br /> Q Other nonprofit Proof previously submitted and on file with the Gambling Control Board <br /> Gambling Premises Information <br /> Name of Establishment where gambling activity will be conducted <br /> Church of St. Genevieve <br /> Street City State Zip Code County <br /> 7087 Goiffon Road, Centerville M:d 55038 Anoka <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> August 16, 1998 <br /> Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> ® *Bingo 0 Raffles 0 "Paddlewheels W" `Pull- tabs 0 *Tipboards <br /> *Equipment for these activities must be obtained from a licensed distributor <br /> e sure the Local Unit of Government and the CEO of your organization sign For Board Use Only <br /> the reverse side of this application. Date & Initials of Specialist <br />