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<br />I . <br /> <br />Minnesota Lawful Gambling <br />LG240B Application- to Conduct Excluded Bingo <br /> <br />(No fee) <br /> <br />Page 1 of 2 <br />8/00 <br /> <br />If your organization has been licensed or exempted in the current calendar year, you are not eligible to apply for excluded bingo. <br /> <br />Organization Information Previous authorization number, if any }{ - 04 7 z.s~z.: <br />Organization Name (as it appears on documentation filed with Minnesota Secretary of State or Internal Revenue Service) <br /> (J~~~V/'/k. L-/O/J ~ C-Ia-b <br />Street <br /> <:/0 M a./ ~:=rf,t!!-e.--~ ..&z." L ,) 7/1/- Z/5+ F/v.e.A/c;>/.,th <br />City State Zip code County <br />C~7-e.rv;/k MN .b~ 0..,3 e3 ~o/~ <br />Type of nonprofit organization (check one): <br /> 0 Fraternal o Veteran <br /> 0 Religious ~ Other nonprofit organization <br />Type of proof of nonprofit - attach a copy (see instructions): rik # Q- S.zc; <br /> 0 Certificate of Good Standing - Minnesota Secretary of State's Office <br /> 0 Internal Revenue Service <br /> 0 Affiliate of parent nonprofit organization (charter) <br />Excluded Bingo Activity Information <br />Has your organization held a bingo event in the current year? <br /> No - Yes.:t- If yes, list the dates that bingo was conducted ~ 22# 7o&'3 <br /> . <br />0 The bingo event will be one of four or fewer bingo events held this year. <br /> Date(s) of bingo event(s) <br /> -OR- <br />~ The bingo event will be conducted (up to 12 consecutive days) in connection with a: <br /> County Fair ----- Date(s) of bingo event <br /> State Fair ------- Date(s) of bingo event <br /> Civic Celebration - Date(s) of bingo event FJLi:J " I) 2. ) Z. aa3 <br />Name of person in charge of the bingo event ~ht' .,i?e./ '/ <br />Daytime Phone (~/2. ).3 ~ €ill - ~q /..3 <br />Premises Where Excluded Bingo Will Be Conducted <br />Name of premises LdL,)v?.J ,/,/..... fJa-r K- <br />L t::LU./ / '-e <br />Street address <br />~97(/ ~"~~--fe ?J,r i t/ c::... <br />City or township County <br /> C~.e r t/ 1'1 Ie?- ~oluL <br /> <br />Be sure to complete page 2 <br />