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For Board Use Only Fee Paid Minnesota Lawful Gambling Page 1 of 2 Check No, Application for Exempt Permit - LG220 10 Initials pp p Receivetl /_/ Organization Information Organization name Previous lawful gambling exemption number Church of St. Genevieve — / C� nU C �? Street City State/Zip Code d County 7087 Goiffon Rd Centerville MN 55038 Anoka Name of chief executive officer (CEO) of organization Daytime phone number of First name Last name CEO: (Rev.) Thomas Fitzgerald 651- 429 -7937 Name of teasurer of organization Daytime phone number of First name Last name treasurer: Diane Kieffer 651- 407 -9660 Type of Nonprofit Organization Check the box that best describes your organization: ❑ Fraternal isn Religious ❑ Veteran ❑ Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: ❑ IRS letter indicating income tax exempt status ® Certificate of Good Standing from the Minnesota Secretary of State's Office p A charter showing you are an affiliate of a parent nonprofit organization p Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Church of St. Genevieve Address (do not use PO box) City State/Zip Code County 7087 Goiffon Rd. Centerville MN 55038 Anoka Date(s) of activity (for raffles, indicate the date of the drawing) August 19, 2000 Check the box or boxes that indicate the type of gambling activity your organization will be conducting: E *Bingo © Raffles ❑ `Paddlewheels ® 'Pull -Tabs ® "Tipboards *Equipment for these activities must be obtained from a licensed distributor. This form will be made available in alternative Your name and and your organization's name Private data about you are available only to the format (i.e. large print, Braille) upon request. The and address will be public information when following: Board members, staff of the Board information requested on this form (and any received by the Board. All the otherinfornation whose work assignment requires that they have attachments) will be used by the Gambling that you provide will be private data about you access to the information; the Minnesota Control Board (Board) to determine your until the Board issues your permit. When the Department of Public Safety; the Minnesota qualifications to be involved in lawful gambling Board issues your permit, all of the information Attorney General; the Minnesota Commissioners activities in Minnesota. You have the right to that you have provided to the Board in the of Administration, Finance, and Revenue; the refuse to supply the information requested; process of applying for your permit will become Minnesota Legislative Auditor, national and however, if you refuse to supply this information, public. If the Board does not issue you apernit, international gambling regulatory agencies; the Board may not be able to determine your all the information you have provided in the anyone pursuant to court order, other individuals qualifications and, as a consequence, may refuse process of applying for a permit remains private, and agencies that are specifically authorized by to issue you a permit. If you supply the with the exception of your name and your state or federal law to have access to the information requested, the Board will be able to organization's name and address which will information: individuals and agencies for which process your application. remain public. law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.