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Minnesota Lawfui Gamb►ing Page 1 of 2 s�os <br />LG220 Applicat�on �o� Exempt �ermi� Fee is $50 for each even� <br />An exemp# permit rnay be issued to a nonprofit organization that: For Board llse Only <br />- conducts lawful gambling on fve or fewer days, and <br />- awards less than $5p,ppD in prizes during a calendar ysar. Check # $ <br />ORGANIZATtON INFQR�ATION <br />Organization name Previous gamblir�g perrr�it r�urnber <br />Rose�ille Central Park Foundation X-b2038-0$-001 <br />Type of nonpro�it organiza#ion. Check ane. <br />�❑ Fraternal � Religious � Veierans � Qther nonprofit organization <br />Mailing address Ci#y S#ate Zip Cade Couniy <br />2660 Civic Cer�ter Drive Roseville MN 55113 Ramsey <br />Name of chief executi�e officer (GEO) Daytime phone number Emaii adcfress <br />Monte oh�son 651-490-9411 <br />Attach a copy of ONE ofi ihe fallowing for proof of nonprofit s'�atus. Check one. <br />Do r�ot attacE� a sales tax exempt status or federal ID employer numbers as they are not proof af nonprofit status. <br />�Nonprofit Articles of Incorporatian OR a current Certificate of Gaod S#anding. <br />Don't have a copy? This certificate rnust be obtained each year from: <br />Secretary of State, Business Ser�ices L7iv„ 180 State Of�ce Bu€Iding, St. Paul, MN 55155 Phor€e: 651-296-2803 <br />�❑ IRS incorne tax exerttption [507 (c)] Ietter in your organization's name. <br />Don't have a copy? To obtain a copy af your federal income tax exemp# letter, have an organization affrcer <br />contact #he 1RS at $77-829-55D0. <br />� IRS - Affiliate of natianal, statewide, or international parent r�onprofit organization (charter) <br />If your organ�zation falls under a parent organization, attach copies of both of the following: <br />a. IRS letter sF�owing ynur parent organization is a nonprofrt 50i{c) o�ganization with a group ruling, and <br />b. the charter or fet�er from your paren€ organization recognizing your organization as a subordinate. <br />� fRS - proof previousfy su6mitted to Gambiing Control Board <br />If yau previously submitted proof of nonprafit status from the IRS, no attac#�ment is required. <br />GAMBLING PREMISES INFORh�ATiON <br />Name of premises where gambfing acti�ity will be conduc€ed (for raffles, list the site where the drawing will take place) <br />Roseville Slcating Center Community Room <br />Address (do not use PO Box) City Zip Code County <br />2b61 Civic Center Drive Roseville �VIN 551�3 Ran�sey <br />Date(s} of activity (for raffles, indicate the date of the drawing) <br />�ctober 2, 2009 to Ociober 2, 2049 <br />Check the box or boxes that indicate the type of garrtbling activity your organization will eonduct: <br />� Bingo"` �] Raffles � Paddlewheels* � Puli-Tabs" �Tipboards" <br />* GamhEing equip�nen� for pu91-tabs, bingo paper, tipboards, and Also complete <br />paddfewheefs must be obtained from a distributor Eicensed by the <br />Gambling Cantrol Baard. EXCEFiIOiV: Bingo hard cards ar�cE binqo Page 2 of t�is form. <br />nurr�ber selection d��ices may be borrowed from another organization <br />authorized to cor�duct binga. Fill-in & Prir�.t Farm <br />To Fnd a licensed distr+butor, go to www.gcb.state.mn.us and dick on List Reset Form <br />o€ Licensed Elistributnrs, or ca[I 651-634-4075. <br />