Laserfiche WebLink
Minnesota Lawful Gambling <br /> Application to Conduct Excluded Bingo - LG240B <br /> If your organization has been licensed or exempted in the current calendar year, you are not eligible to apply for excluded <br /> bingo. <br /> Organization Information FOR BOARD USE ONLY <br /> Organization Name /► Proof <br /> e V ;)L LION ell t Si 1 c 1 <br /> Street L O I N NA F <br /> /8[9 Q 'APSE"- s +vee-T Other Activity <br /> City County State /Zip <br /> 012.k twi l A„n AN ssn3f <br /> Type of nonprofit organization (check one): <br /> g Fraternal ❑ Veteran <br /> Religious ❑ Other nonprofit organization <br /> Type of proof of nonprofit - attach a copy (see instructions): <br /> ❑ Certificate of Good Standing - Minnesota Secretary of State's Office <br /> ❑ Internal Revenue Service <br /> ❑ Affiliate of Parent nonprofit organization (charter) • <br /> Excluded Bingo Activity Information <br /> Has your organization held a bingo event in the current year? No ` Yes <br /> If yes, list the dates that bingo was conducted <br /> Check one: <br /> [;2? The bingo event will be one of four or fewer bingo events your organization will hold this year. <br /> Date(s) of bingo event JNly 0 8 (29 36 <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 <br /> Name of the person in charge of the bingo event Daytime Phone <br /> Mo -Lt% ( bsi ) ilack Sala <br /> Premises Where Excluded Bingo Will Be Conducted <br /> Name of Premises <br /> J.at Mo-F} e. parr; <br /> Street Address <br /> 6907 La Mo-Ne Dri VC <br /> • <br /> City Jar County Township <br /> en &V /IQ <br /> Be sure to complete page 2 Page 1 of 2 <br /> 3/99 <br />