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• <br /> Minnesota Lawful Gambling Page 1 of 2 nos <br /> Application fee <br /> LG220 Application for Exempt Permit If application cos marked orreceived: <br /> An exempt permit may be issued to a nonprofit organization that less than 30 days more than 30 days <br /> - conducts lawful gambling on five or fewer days, and before the elant before the event <br /> awards less than $50,000 in prizes during $ ng a calendar year. <br /> ORGANIZATION' INFORMATION , chedr# <br /> Organization name Previous gambling permit number <br /> Centerville Lions Club X - 04725 <br /> Type of nonprofit organization. Check one. (---� <br /> I ^ 1 Fraternal I I Religious uVeterans ! I Other nonprofit organization <br /> Mailing address City State Zip Code County <br /> 7155 Brian Drive Centerville MN 55038 Anoka <br /> Name of chief executive officer (CEO) Daytime phone number Email address <br /> Lisa Kleselhorst 612- 221 -9141 Lisa @comcestnet <br /> Attach a copy of= of the.foliowing for proof of nonprofitstatus: Check one. <br /> Do not attach a sales tax exempt status or federal ID employer numbers as they are not proof of nonprofit status. <br /> I I Nonprofit Articles of Incoiporation OR a current Certificate of Good Standing. <br /> f Don't have a copy? This certificate must be obtained each year from: <br /> Secretary of State, Business Services Div., 180 State Office Building, St. Paul, MN 55155 Phone: 651-296-2803 <br /> L__J IRS income tax exemption 1601(01 latter 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 officer <br /> contact the IRS at 877 - 829 -5500, <br /> n IRS - Affiliate of national, statewide, or international parent nonprofit organization (charter) <br /> if your organization falls under a parent organization, attach copies of Qoth 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 /> I ^ I IRS - proof previously submitted to Gambling Control Board <br /> If you previously submitted proof of nonprofit status from the IRS, no attachment is required. <br /> GAMBLING PREMISES. INFORMATION <br /> Name of premises when gambiing"activity will be conducted (for raffles listthe site where the Will takeptabe) <br /> Centerville Lake; Centerville Lion Prize Area <br /> Address (do not use PO box) City Zip Code County <br /> 7281 Hwy 14 • Centerville 55038 Anoka <br /> • <br /> Date(s) of activity (for raffles, indicate the date of the drawing) <br /> Ice Fishing Contest Saturday, February 20th 2010 <br /> ) Check the box or boxes that indicate the type of gambling activity your organization will,conduct: <br /> 0Bingo* ®Rattles DPaddlewheek• ❑Pull -Ts bs` DTipboards* <br /> *Gambling equipment for pull -tabs, bingo paper, tipboards, and Also complete <br /> paddlewheels must be obtained from a distributor licensed by the <br /> Gambling Control Board. EXCEPTION: Bingo hard cards and bingo Page 2 of this form. <br /> number selection devices may be borrowed from another organization <br /> authorized to 'conduct bingo. ' "p> .;1 <br /> To find a licensed distributor, go to www.gcb.state.mn.us and dick on List ` xYS ^= <br /> of licensed Distributors, or call 651 - 639-4076. (te5etftY; <br /> 35 <br />