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MINNESOTA LAWFUL GAMBLING <br /> LG240B Application to Conduct Excluded BingoNo Fee 6,15 <br /> "►RGANIZATION INFORMATION Page 1 of 2 <br /> Organization <br /> Name: Centerville Elementary PTA Previous Gambling <br /> Minnesota Tax ID <br /> Permit Number: XB-36441 <br /> Number, if any: 20-5965053 Federal Employer ID <br /> Mailing Number(FEIN), if any: <br /> Address: 1721 Westview Ave <br /> City: Centerville State: MN zip: 55038 <br /> County: Anoka <br /> Name of Chief Executive Officer (CEO): Becky Burnham <br /> Daytime Phone: 651.983.6246 Email: tbburnham@comcast.net <br /> NONPROFIT STATUS <br /> Type of Nonprofit Organization (check one): <br /> Fraternal EIReligious ElVeterans ✓ <br /> Other Nonprofit Organization <br /> Attach a copy of at least one of the following showing proof of nonprofit status: <br /> (DO NOT attach a sales tax exempt status or federal employer ID number, as they are not proof of nonprofit status.) <br /> Current Certificate of Good Standing <br /> Don't have a copy? This certificate must be obtained each year from: <br /> MN Secretary of State, Business Services Division <br /> 60 Empire Drive, Suite 100 Secretary of State website, phone numbers: <br /> St. Paul, MN 55103 www.sos state mn.us <br /> 651-296-2803, or toll free 1-877-551-6767 <br /> Internal Revenue Service-IRS income tax exemption 501(c) letter in your organization's name <br /> Don't have a copy? Obtain a copy of your federal income tax exempt letter by having an organization officer contact <br /> the IRS at 877-829-5500. <br /> Internal Revenue Service-Affiliate of national,statewide, or international parent nonprofit or anizati <br /> If your organization falls under a parent organization, attach copies of both of the following: g on (charter) <br /> 1. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <br /> 2. the charter or letter from your parent organization recognizing your organization as a subordinate. <br /> EXCLUDED BINGO ACTIVITY <br /> Has your organization held a bingo event in the current calendar year? O Yes ✓ <br /> No <br /> If yes, list the dates when bingo was conducted: <br /> The proposed bingo event will be: <br /> ❑✓ one of four or fewer bingo events held this year. Dates: 11.13.15 <br /> -OR- <br /> conducted on up to 12 consecutive days in connection with a: <br /> county fair Dates: <br /> 11 civic celebration Dates: <br /> E]Minnesota State Fair Dates: <br /> Person in charge of bingo event: Shannon Swanson <br /> Daytime Phone: 651.208.4370 <br /> me of premises where bingo will be conducted: Centerville Elementary <br /> LPrem,ses street address: 1721 Westview Ave <br /> nterville If township, township name: <br /> County: Anoka <br /> 19 <br />