Laserfiche WebLink
, <br /> LG220 For Board Use Only <br /> ' , Revosrss Minnesota Lawful Gambling <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 )( Ci <br /> 9 ?CO <br /> Street City State Zip \ Code d 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 (61) 429 -7937 <br /> Name of Organization Treasurer Day time Phone Number of Treasurer <br /> First Name Last Name <br /> Diane 1 Kieffer (6l 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 /> 0 Fraternal <br /> O IRS letter indicating income tax exempt status <br /> Q Veterans RI Certificate of good standing from the Minnesota Secretary of State's office <br /> _; Religious 0 A charter showing you're an affiliate of a parent nonprofit organization <br /> 0 Other nonprofit 0 Proof previously submitted and on file with the Gambling Control Board <br /> 1 <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 /> (J *Bingo Er Raffles C] *Paddlewheels ® *Pull-tabs ED *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 /> e reverse side of this application. Date & Initials of Specialist <br />