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MINNFSOTA LAWFUL GAMBLING 6/13 Page 1 of 2 <br />L+G240B Application to Conduct Excluded Bingo No Fee <br />ORGANIZATION INFORMATION <br />Organization nand k Try Previous gambling permit <br />Vl — 2 <br />Minnesota tax ID number, if any Federal employer ID number (FEIN), if any <br />Type of nonprofit organization, Check one. <br />Fraternal Religious Veterans X, Other nonprofit organization <br />Mailing address CitX State Zip code County <br />N of chief e�ecutiv er CFO Daytime phone numberE-mail address <br />NONPROFIT STATUS <br />Attach: a copy of ONE of the following for proof of nonprofit status. <br />Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. <br />Don't have a copy? This certificate must be obtained each year from: <br />Secretary of State, Business Services Div., 60 Empire Drive, Suite 100, St. Paul, MN 55103 <br />Phone; 651-296-2803 <br />IRS income tax exemption [501(c)] letter in your organization's name. <br />Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization <br />officer contact the IRS at 877-829-5500. <br />IRS - Affiliate of national, statewide, or international parent nonprofit organization [charter] <br />If your organization falls under a parent organization, attach copies of 'both of the following: <br />a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />EXCLUDED BINGO ACTIVITY <br />I. No Yes Has your organization held a bingo event in the current calendar year? <br />If yes, list the dates when bingo was conducted. <br />2. The proposed bingo event will be: tq/ <br />one of four or fewer bingo events held this year. Dates <br />0R <br />conducted on up to 12 consecutive days in connection with a: <br />county fair. Dates <br />civic celebration. Dates <br />_ Minnesota state fair. Dates GG <br />3. Person in charge of bingo event / r "�� Daytime phone Z�o� <br />4. Name of premises where bingo wili be conducted <br />5. Premises street address112-1 <br />Vie k(AN -A �j <br />6. Cite. �r'l lV r - If township, township name County 'i \C o k. <br />Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized <br />to conduct bingo. Otherwise, bingo hard cards, bingo paper, and bingo number selection devices must be obtained <br />from a distributor licensed by the Minnesota Gambling Control Board. To find a licensed distributor, go to <br />www.gcb.state.mn.us and click on Distributors under the WHO'S WHO? LIST OF LICENSEES, or call <br />651-539-1900. Be sure to complete page 2 <br />-14- <br />