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1/10 Minnesota Lawful Gambling Page 1 of 2 LG240B Application to Conduct Excluded Bingo No fee ORGANIZATION INFORMATION Organ' tion name Previous gambling permit number Type of nonprofit organization. Check (') one. I - ❑ Fraternal ❑ Religious ❑ Veterans (] Other nonprofit organization Mailing address City State /Zip Code I County 1 W tsiv e w' - A-V-e. 0 n+c.r vi I le M N 1;5 S A-In 0 Kai ATTACH A COPY OF ONE OF THE FOLLOWING FOR PROOF OF NONPROFIT STATUS * Do not attach a sales tax exempt status or federal ID employer number as they are not proof of nonprofit status. Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. Don't have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div., 180 State Office Building, St. Paul, MN 55155 Phone: 651- 296 -2803 Internal Revenue Service - IRS income tax exemption [501(c)] letter in your organization's name. Don't have a copy? To obtain a copy of your federal income tax exempt letter, have an organization officer contact the IRS at 877 - 829 -5500. _Internal Revenue Service - Affiliate of national, statewide, or international parent nonprofit organization (charter) If your organization falls under a parent organization, attach copies of both of the following: a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and b. the charter or letter from your parent organization recognizing your organization as a subordinate. _Internal Revenue Service - proof previously submitted to Gambling Control Board If you previously submitted proof of nonprofit status from the Internal Revenue Service, no attachment is required. EXCLUDED BINGO ACTIVITY No &Yes Has your organization held a bingo event in the current calendar year? If yes, list the dates when bingo was conducted T Z 6 -L4 J7,4 2 (e i 2 o l 2. The proposed bingo event for which we are applying will be: one of four or fewer bingo events held this year. Dates OR _conducted up to 12 consecutive days in connection with a: _county fair. Dates civic celebration. Dates _Minnesota state fair. Dates 3. Person in charge of bingo event 5 vo - Yt.vuUVl 4. Name of premises where bingo will be conducted �✓ I < <� 5. Premises street address I 2 I aj e-S�' i� Vv , 6. City Le_V V I 1 1e If township, name of township Daytime phone (p ( `4 "D2U2- County AV Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized to conduct bingo. Otherwise, bingo hard cards, bingo paper, and bingo number selection devices must be purchased from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb.state.mn . us and click on List of Licensed Distributors. Or call 651 - 639 -4076. Be sure to complete page 2 14