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LG220 For Board Use Only <br /> - Revue% Minnesota Lawful Gamblin <br /> Application for Authorization for an Fee Paid <br /> Exemption from Lawful Gambling License neck # <br /> Initals <br /> Date Recd <br /> Organization Information <br /> Organization Name Previous lawful gambling exemption number <br /> Church of St. Genevieve X 9 ? d c ? <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 (612 429 -7937 <br /> Name of Organization Treasurer y <br /> First Name Last Name Daytime Phone Number of Treasurer <br /> Diane Kieffer <br /> 612) 429 -5069 <br /> Type of Nonprofit <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 /> 0 IRS letter indicating income tax exempt status <br /> Fratemal <br /> Certificate of good standing from the Minnesota Secretary of State's office <br /> O Veterans <br /> ® Religious 0 A charter showing you're an affiliate of a parent nonprofit organization <br /> 0 Other nonprofit O Proof previously submitted and on file with the Gambling Control Board <br /> Gambling Premises Informatio <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 /> May 21, 1997 <br /> Check the box or boxes which indicate the type of gambling activity your organization will be conducting <br /> [] 'Bingo i n Raffles O "Paddlewheels 0 *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 For Board Use Only <br /> e reverse side of this application. Date & Initials of Specialist <br />