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Rev06 96 Minnesota Lawful Gamb ling For Board Use Only <br /> Application for Authorization for an Fee Paid <br /> Exemption from Lawful Gambling License Check # <br /> Initals <br /> Date Recd <br /> Organization Information <br /> Organization Name Previous lawful gambling exemption number <br /> Church of St. Genevieve X c t ) gU d F <br /> Street City State Zip Code 4 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. Richa J. Molter (61) 429 -7937 <br /> N ame of rganization Treasurer Y <br /> First Name Last Name Daytime Phone Number of Treasurer <br /> Diane Kieffer (61� 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 /> El Fraternal IRS letter indicating income tax exempt status <br /> D Veterans E3 Certficate of good standing from the Minnesota Secretary of State's office <br /> Religious A charter showing you're an affiliate of a parent nonprofit organization <br /> 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 MN 55038 Anoka <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> August 17, 1997 <br /> Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> 1 FA "Bingo E3 Raffles [:] *Paddlewheels ® 'Pull -tabs 0 *Tipboards <br /> *Equipment for these activities must be obtained from a licensed distributor <br /> sure the Local Unit of Government and the CEO of your organization sign <br /> For Board Use Only <br /> e reverse side of this application. Date & Initials of Specialist <br />