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<br />Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit <br />An exempt perm~ may be issued 10 a nonprofit organization ll1at <br />_ conducts lawful gambling on five or __ days, and <br />_ awar<ls taas than $50 000 In prizes during a calendar year <br /> <br />Page 1 of 2 9108 <br />Fee is $50 for each event <br /> <br />For Bosrd Use Only <br /> <br />ORGANIZATION INFORMATION ........ . .... ....ii '. '.' .'. .'. <br />Or~anlzation name Prellious gambling permit number <br />Centerville Uons Club X-ll472S-ll9-ll01 <br />--. <br />Type of nonprofit organization. Check one, <br />[Q] Fraternal [Q] Religious [Q] Vetersns ~ Other nonprofit organization <br />Mailing address City Slate Zip Code County <br />7155 Brian Dr. Centerville MN 55038 Anoka <br /> . <br />Name of chief executive officer (CEO) Daytime phone number Ema" address <br />Jon Kvamme, P,_ldent . 651.282.0433 jon.a.kvamme@medtronic.com <br />Attach a copy of QJg of the following forprQOt of nOI'lp~~tli..Checl( one; .... .... . '. . <br />00 not attach a sales tax exempt status or federallD employer numbers as they are not proof of nonprofit status. <br />I 01 Nonprofit Artfcles of IncorpOl3llon OR a curl8nt certificate of Good Standing, <br /> Don~ hIDIe a copy? This certifioete must be obtainell each yea' from: <br /> Secretary of State. Business Services Div" 180 State Office Building, SI. Paul, MN 55155 Phone /351.296-2803 <br />[Q] IRS income ta. exemption [601(cl1_r In your organization's name. <br /> Don't have a copy? To obtain a copy of your federaf income tax exempt letter, have an organization officer <br /> contact the IRS aI877-829-MOO. <br />!Q] IRS. AflIIiate 01 nallonol, 8latBWlde, or international parOnl """profit organization (chartBl'\ <br />If your organization falls under a PB",m organization, attach copies of b.!!l!Lof the following: <br /> a, IRS letter showing your parent organizetion is 8 nonprofit 501{c) organization with a group ruling, and <br /> b. the charter or letter from your parent organization recdgnizing your organization as a subordinate. <br />lilSJIIRS. proof previously submitted to Gambfing Control Board <br /> II you p",viously submitted proof of nonprofit status from tha iRS, no attachment is requil8d. <br />GAMBLING PREMiSeS INFORMAflON . <br />Neme of premises where gambling adivily Will be conducted (for raffles, li$l1he site wha'" the drawing will take place) <br />I.aurle LaMotte Memorial Park <br />Address (do not use PO box) City Zip Code Govnty <br />Laurie LaMotte Memorial Park Centerville 55038 Anoka <br />Oale{s) of.Ciivtty (for ,ofiles,lndiea1x! the dale of the dnlwing) <br />0810912009 \0 0810912009 <br />~eck the box or boxes thai indicate the type of gambling activity your organization will ""nduct: <br />o Bingo" I2:J Raftles o Padd_I.. OPul- T abe" []Tipboards" <br /> . Gamblllll_ipment for pul-tabs, bingo paper, tlpboards, and .- <br /> paddIewheeIs must be obtained from a dlstributDr Ilc:ensed by the IpAlse complete ..1 <br /> Gambling Control BolIn!. ElCCB'TlON: Bingo hard cards and bingo Page 2 of this form. <br /> number seIeclIon _ may be bofnMel from another organl2atlon IM\II <br /> authorized \0 conduct bingo. <br /> To find a Ucensed di~. go to www.gcb.stale.mn.lISanddlckon Us! ~ <br /> of Ucensed OistributXlrs, or call OS 1-639-4076. <br /> <br />Gheck II <br /> <br />$ <br />