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Minnesota Lawful Gamblin Pagel of 2 1/11 V Application fee for each event _G220 Application for Exempt Permit I sop ca on postmarked or received: less than 30 days more than 30 days An exempt permit may be Issued to a nonprofit organization that: - conducts lawful gambling on five or fewer days, and before the event before the event - awards less than $50,000 in prizes during a calendar year. $100 $50 ORGANIZATION INFORMATION Checks $ Organization name Previous gambling permit number Centerville Lions Club X -04725 Type of nonprofit organization. Check one. Fraternal E Religious ❑ Veterans X Other nonprofit organization Mailing address City State Zip Code County 7155 Brian Drive Centerville MN 55038 Anoka Name of chief executive officer (CEO) Daytime phone number Email address John Thlll 651453 -4641 itbandk @comcest.net Attach a copy of DE of the following for proof of nonprofit status. Check one. Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. ❑ Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. Don1 have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div., 180 State Office Building, St. Paul, MN 55155 Plane: 651- 296-2803 IRS Income tax exemption [501(c)] letter In your organization's name. Don't have a copy? To obtain a copy of your federal Income tax exempt letter, have an organization officer contact the IRS at 877.829 -5500. XI IRS - Affiliate of national, statewide, or International parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of ILoth of the following: a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and b. the charter or letter from your parent organization recognizing your organization as a subordinate. GAMBLING PREMISES INFORMATION Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Centerville Lake; Centerville Lion Prize Area Address (do not use PO box) City Zip Code County 7281 Hwy 14 Centerville 55038 Anoka Date(s) of activity (for raffles, Indicate the date of the drawing) Same Day Raffle on Saturday February 18th 2012 heck the box or boxes that indicate the type of gambling activity your organization will conduct: ❑ Bingo' ® Raffles Paddlewheels' Pull -Tabs' ❑Tipboards' • Gambling equipment for pull -tabs, bingo paper, tipboards, and Also complete paddlewheels must be obtained from a distributor licensed by the Gambling Control Board. EXCEPTION: Bingo hard cards and bingo Page 2 of this form. number selection devices may be borrowed from another organization authorized to conduct bingo. print farm To find a licensed distributor, go to www.gcb.state.mn.us and click on List ResetFartn of Licensed Distributors, or call 651- 639 -4000.