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MINNTSOTA I.AWFUL (rAMRLING
<br />LG2�0 Appi►cation for Exempt P�rmit
<br />An exempt permit may he IssurA ko a nonpinfit or�anizatinn that:
<br />- conducts lawtul gainblin4 on tive or fewei� days, anii
<br />- awards less than $50,000 In prizes during a calendar year.
<br />If Cofal prize value for the y<��ar will be SJ.,500 or less, r.unfa�tthe Ilcc:nsin�,
<br />specialist assigned to your county, �
<br />ORGANIZATION INFORMATION
<br />Organiza,{iun name -
<br />I` f _ �: I ,1! .�n .. .., i � ( -- .. . .. ..� i% n ;-.... � ,,. i` .�,: r�.. ... r,�
<br />1/13 pa�e i. of ?.
<br />__.___.._ .. __'.____. .____... _ ____.._ . ____._.._.
<br />/app�ICOtlOt1 feC (non re.tundablr)
<br />7f aUPllcatlun Is postmnrked or received 30 days or _
<br />mnrn b�;FUro Che arvenf �50; ofheiwlsr $100,
<br />__... _... J
<br />�_._..... -_. ... .
<br />...____..^.--- -----_—�.�. / !
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<br />Prevluus c�Amblin9 permit number
<br />Minnc�soFa tax ID niambcr, If any Federe�l employer lu number p'L'-IN), IF uny
<br />�,j, �! �`;.%��) I LkC� ,
<br />7ype of nonprofit orpanization. ClreCi< one.
<br />_ Fraternal _Re119ious _VeteYans �Other nonproflt organization
<br />Ma�ltn� address • City Skake "l_ip.code County
<br />N�ine of chief e�ceu.it'Ive offlcer [Cf-Oj Dzytlme phone� number [- all addrgss
<br />_\r�lr,n (-�-„i'? I,n;��,,. ��G�_'�-L1fn •GI�'�1�7 �-�,�F'1f`P.1��
<br />NOIVPROFYT S7ATI�S
<br />�Atta h a copy of ONE of the folfowing far proof pf nanprofit status.
<br />Nonprofit Articles of Tncorporation.OR a currant�Certificate of Good Standing. �
<br />Dun'I: have a copy7 Thls certlflcaCe rnusY be nbl�alnerJ each year fl•om:
<br />Secretary of State, Business Servlces Div., GO Empire Drive, SuiEe 100, St. Paul, MN SSS03
<br />Phone: 6i1-2§6-28tJ�
<br />__ IRS income tax. exemption [501(c)] letter in your arganization's name.
<br />tJon't have a cqpy"1 "fo obtaln a capy of your federal income tax excmpF. IetCer, have an organizakion offlcer conkact
<br />the 1RS at 677-629-5500. . �
<br />_ IRS - Affiliate of natianal, stakewide, or inkerna¢ional parenk nonFXafit organization [charter]
<br />1P yc�ur organizakia�i falla under a pair.nt prg¢�nizatipn, aCte�d� copi2e af bnfCt of the followlny: ,
<br />a. � iRS letter showin� your parent or9anlzatfon is a nonpfoflt 501(c) orgaNzatlon with a group�ruling, :�nd
<br />G. the charter or IeCter from your parenf org�nlzation recoqnlzinn Y�ur nrgenization as a subordlnaCe.
<br />GAMBLING PREMISES INFORMATTON
<br />Ndrtt�: of pre;,r�lse� wh �(e I-.lie �,�rr}kjlinyyt�Venk will be. mndur.[ed. 1=��r i-eifNes� Ilsl Ihe sile whcre Che drawfn9 wlll CakE pleir.�,
<br />Address [do not use PO box] � , C���� ^r F .chln � Zlp code
<br />lj {„/' , A , . .
<br />� } � :. � ���_ �� ��..� ���:�'r'!l �-----��---��.-���=
<br />\7._1.�..-l. °
<br />Date[s) of ucllvlly For ratflles IndlcaL�c,nlhe dale of Fhe dr�7winp.
<br />Li. _.(.p A�l� 1 I'a .iA % U l.-�: . 1� ,r,�(•'l
<br />Check each type of gambling �tivlty that you}- organlzatlon will conduct.
<br />i
<br />_ F}inqo' � RaPfle _P�ildlawheels* Pull-tabs� _'I-IpbanrAs*
<br />�
<br />*Gambling equipment for binc�o paper, paddlewheels, pull-tabs, and tipbuards must ba obtained frum a dlstrlbutor '
<br />Iicensecl, Uy fhe Minn�asota G�rnblinq Contrvl ESUZir�. EXCEPTION; 6tnyo harci cards �ncl Grin�� i�ambF�r seiGr,UOn rinvices
<br />may be borrowed frn�n anofher or9aniz.atlon r�uthorized to condoct binpo,
<br />7o flnd a Ilcensed dtstrlbulnr, t�t� to www.gcb,state.mn.us and cIICk on Olst�lbuNors
<br />under the WHO S WH07 IIST OF LICEMSEES, or call 651-539-1900.
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