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Attachment A <br />Minnesata Lawfuf Gam�ling <br />LG2Z0 Applicativn for Exemp� Permit Fee is $5Q �ar eaehaevent���a <br />An sxempt permit may be issued ta a nonprofit organization that: <br />- conducts law€ul gambling on Fve or fewer days, and Far Board Use Only <br />- awards less ihan $50,000 in prizes during a cafendar year. Check # <br />$ <br />ORGANIZATION IN�ORMATIQN <br />Orgar�izaiian name Previous gambling permit nurrfber <br />St. Rose of L�ma Catholic Church <br />x - �oar�oa. <br />iype of nonprofit orga�ization. Check one. <br />� Fraterr�al � Religious � Veterans � Other nonprofit organizatio� <br />Mai(ing address Gify State Zip Code Cour�ty <br />204�8 Hamline Ave. N. Roseville MN 55113 Ramsey <br />Na�e of chief executive ofticer (CEO) Daytirr�e phone number Email address <br />Robert :7. Fitzpatric� 651-357-1201 fr�itz@saintroseoflima.n r <br />Attach a copy of QNE of the foilowing for proaf of nonprofit status. Check one. <br />Do not a�tach a sales tax exempt sta�us gr federa! ID empfoyer r��rnb�rs as they are not proof of nonprofit status. <br />� Nonprafit Articles of Incorporatian OR a current Cer'tifiicate ofi Goad Standing. <br />Dpn't have a copy? This certificaie musi b� obtained each year from: <br />Secretary af State, Business Services [�iv„ 180 State O�ice Building, St. Pauf, MN 55155 pi�one: 651-296-28D3 <br />� IF2S ineame tax exemptipn [501(c)] lette.r in youc organization's rtame. <br />Don't have a copy? Ta obtain a copy of your federal incorne tax exempt letter, have an orgar�ization officer <br />contact the �RS at 877-829-550p. <br />� iRS - Affiliate of national, statewide; or irtterna.tianai parent nonprafit organizatio� (charterj <br />If your organization falls u€�der a pare�t organization, attach eopies of both of the following: <br />a. IRS letter showing your parent arganization is a nonprofrt 501(c) organization with a group rufing, and <br />b. the c�arter or letter fram your parent arganization recagnizing your organization as a subordinate, <br />� IRS - prooP previously suhmitEed to Cambling Contrpf Board <br />li you pre�iousiy svbmitted proof of nonprofit sta.tus from the IRS, no attachment is required. <br />GAMB�.ING PREMISES 1NFORMATION <br />Name of premis�s where garrtbling aciivity uvsll be conducted (for rafFies, list ihe sits where the drawing will take place) <br />MidZand Hills Country C1ub <br />Address (do nat uss PO box) City Zip Code County <br />20QI Fulha�n Street Roseville 55113 Ra�nsey <br />Date(s) of activity (far raffles, indicate the date oF th� drawing) <br />May 16, 2QOg tO May 16, 2009 <br />;heck the bax or boxes that indicate the rype of gamb€ing activity your orgarsizatian will canduct: <br />� Bingo' X� RafFles � Paddlewheels� � pull-iabs* [� Tipboards* <br />* Gambiing ec�uiprnent. far pull-tabs, binga paper, Eipboards, and <br />paddlewh�els must be obtained from a distr�butor licensed by the <br />Gambling Controf Board. EXC�PTION: 8ingo hard cards and bingo <br />number selection devices may be barrowed from anaEher organization <br />authorized to conduCt bingo. <br />To �ind a licensed distributor; go ta www.gcb.s�ite.mn.us and ciick on Lisr <br />of Lieensed Qistributors, or call 651-639-4076. <br />Also complete <br />Page z of this form. <br />�rll in &'Print`Forrn:< <br />'ResetForm. <br />