1997-02-26 - CC Packet - (Admin.)

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Rev O6/96 Minnesota Lawful Gambling For Board use Only Application for Authorization for an Fee Paid Exemption from Lawful Gambling License Check # Initals Date Recd Organization Information Organization Name Previous lawful gambling exemption number Church of St. Genevieve X 7 ? d b 8 Street City State Zip Code County 7087 G oiffon R oad Centerville MN 55038 Anoka Name of Chief Executive Officer of organization (CEO) Daytime Phone number of CEO First Name Last Name Rev. Richard J. Wolter (61) 429 -7937 Name of Organization reasurer Da time Phone Number of Treasurer First Name Last Name Y Diane Kieffer 612) 429 -5069 Type ofNonprofit Organization Check the box below which best describes Check the box that indicates the type of proof attached to this application your organization by your organization: Q Fraternal IRS letter indicating income tax exempt status [] Veterans 0 Certificate of good standing from the Minnesota Secretary of State's office E2 Religious El A charter showing you're an affiliate of a parent nonprofit organization 0 Other nonprofit Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information Name of Establishment where gambling activity will be conducted Church of St. Genevieve Street City State Zip Code County 7087 Goiffon Road Centerville MN 55038 Anoka Date(s) of activity (for raffles, indicate the date of the drawing) May 21, 1997 Check the box or boxes which indicate the type of gambling activity your organization will be conducting 0 'Bingo F1 Raffles 0 "Paddlewheels Q 'Pull -tabs 0 'Tipboards *Equipment for these activities must be obtained from a licensed distributor sure the Local Unit of Government and the CEO of your organization sign For Board Use Only the reverse side of this application. Date & Initials of Specialist