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For Board Use Only <br /> Minnesota Lawful Gambling Fee Paid <br /> Application for Exempt Permit - LG220 Check No. <br /> Initials <br /> Organization Information Received <br /> Organization name Previous lawful gambling exemption number <br /> Church of St. Genevieve X X2 60 $ <br /> Street City State /Zip Code County <br /> 7087 Goiffon Road, Centerville, MN 55038 Anoka <br /> Name of chief executive officer (CEO) of organization Daytime phone number of <br /> First name Last name <br /> CEO:( 651 ) 429 -7937 <br /> (Rev.) Richard J. Wolter <br /> Name of teasurer of organization Daytime phone number of <br /> First name Last name <br /> treasurer. (651 ) 429 -5069 <br /> Diane Kieffer <br /> Type of Nonprofit Organization <br /> Check the box that best describes your organization: <br /> ❑ Fraternal Religious <br /> ❑ Veteran ❑ Other nonprofit organization <br /> Check the box that indicates the type of proof your organization attached to this application: <br /> ❑ IRS letter indicating income tax exem t status <br /> Certificate of Good Standing from the Minnesota Secretary of State's Office <br /> ❑ A charter showing you are an affiliate of a parent nonprofit organization <br /> ❑ Proof previously submitted and on file with the Gambling Control Board <br /> Gambling Premises Information <br /> Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br /> Church of St. Genevieve <br /> Address (do not use PO box) City State/Zip Code County <br /> 7087 Goiffon Road, Centerville MN 55038 Anoka <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> November 8, 1998 <br /> Check the box or boxes that indicate the type of gambling activity your organization will be conducting: <br /> 'Bingo ❑ Raffles ❑'Paddlewheels ❑'Pull -Tabs ❑ <br /> 'Equipment for these activities must be obtained from a licensed distributor. <br /> This form will be made available in alternative format (i.e. large print, Braille) upon request. <br /> The information requested on this form will become public information when received by the Board, and will be used to determine <br /> your compliance with Minnesota statutes and rules governing lawful gambling activities. <br /> Page t of 2 <br /> 3198 <br />