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MINNESOTA LAWFUL GAMBILLING 6/15 <br />1111 G7401B As2inlicatinin to Conduct Excluded Blingo INo Fee Ift-gel of 2 <br />OIRGAISI' A"1111 101N INFORINATIOIN <br />Oiij...janlzatlt:1! 1-11 0 previoii.,is Gambilling <br />Peffnlit Nurniben .............. . ...... <br />Mininesota Tax ID U., r, Federal Employer 1ID lyl 0 1 V�� <br />Nurnber, if any: 17 9 14 9r7 U2 vl� Number (FIl"1111), If any: ................. <br />mailling <br />Address: I WPr�V& C7 L . ..................... <br />staw..r tA_j_ <br />ClIty.. ............... VZI[Ip" w t,gnty . ........................ <br />Name of Chief 1:..:XecutWe Officer (CEO),. <br />3U <br />_V1_ (0— Email: O&Lw( <br />Daydirne Phone" -Al kffi­-Bm&2^4( <br />NONPROM STATUS <br />'rype of Noniprofit Orqainization (i.-terk one):: <br />Fraternal) Religious"' ®R Other NonpinAt Organization <br />Attadha CW of at 1118WIt.922, Of U-1116 folljowiling slbzwllng pilroof of vionpiirafft SWUM <br />. ....................... . .......................................................... . <br />(DO NOT attacb a salleso tax exempt SWtUS or fpderall ernployer 1D nurnIber, a!!� they are not proof of nonprofit status.) <br />EDQi rrept calendar yorar CartlificaW of Gii[jod standratq <br />Don't, have a aDIpy? rhils, certificate imust Ilse otkained each yeair frorru <br />i <br />IMI[ SecrKary DIF c5taixp., BusIness Serv!CSS Division Secretary of.State website, phone inuimWns., WaW .Ias� <br />60 1:..:ArnpI[irP. DrIvHn e, qu1.00 �Sr 7-55:1 6767 <br />St.. Paull, MIN 55103 651 296-2803, or toll ftw. 1-87 <br />E] Tntemall Revenue Seirvice„,.Vitt lincome -tax exemption 1501(c) III it lin ymixir organNur tIon's 111131me <br />Don't. have a copy? Obtain a copy of your federal Jjrjaome tax exeimpt left r by having an orgainizationi offt"N' WnWt <br />tyre II at 877-829-5500., <br />01fternall Raveirime SerWre-Alffillilats ar =111:1101�'Iwll, stift"WWeir or International pairent noinpiraflt orpintration (chaiiiteir) <br />If youfl-� orgal-gzadou,j falls under a pairent owyjainization, coples of lWth of: tl�je follawinq: <br />1_ IRS letter showing your parent organization iis a irwonprofit,501(c) orgainilzation with a groulp rulfing, and <br />2w the charbar or letter from your parent orgainlIzailJoin recognizing youir orgainiiation as a subordinate, <br />EXCLUDED BINGO ACTIVM, <br />Has your. ani!zation(bell d a ijingo event. in the current raliondar yflar? El ye., pio <br />:Ef yos, ftt the dates when bingo was conducted' <br />rhe proimsed bingo event waw illi be'. ZAD I I <br />Q <br />one iDf fbior, or fewer Wngo events held this year., Dates . ................ LW CM A, L —7- 4 ”- r —' <br />�71 rnn&.irted on up'to:12 cOMmutive days'jin coinnemfflon with a', <br />..])unty rawir <br />1)rdtes!, <br />Elcivic rnlebration <br />Dates:: <br />11 Minnesota State Fair <br />Datf,S.' <br />V t P.A. <br />j <br />Person in rharge of bingo evervt:: ........... <br />... .. ...... <br />....... ........ <br />Daytime Pi'lione . ......... url-L.LL Pri _­';1MV <br />iIl'l � I I I I W <br />Nairneorlproniiseswlherplblngowllllllll:)er.anductod::,--.L /V A <br />Pire,irnises,greet address; .......... <br />Iftownship, tDwnship name . ...... . .................. . ............... . . . ..... . . ................ . . __ County" kVX0_U_ <br />RE <br />