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Minnesota Lawfuf Gambling <br />LG220 Application for Exer�p� Pe�-rnit <br />An exempt perrnit may be issued to a nonprofit orgarsiza#ion that: <br />- conducts iawful gambling on five or fewer days, and <br />- awards less than $50,OOQ in prizes during a calendar year. <br />RGANIZATiOiV INFOR�NNATION <br />Organization name <br />Raseville Volur�teer Fire Depa�tment Auxiliary, <br />Attachment A <br />� or z 7ios <br />Ap <br />Ei a ucaE�on ostmarKea or received: <br />less than 30 days more than 30 days <br />before the e�er�t be€ore the event <br />$10D $5U <br />Check # $ <br />Previnus gambling permit number <br />X-05702 <br />Type of nonprofit organization. Gheck one. <br />❑� Fraternaf �❑ Re[igious �Veterans �� Other nonproft organizatinn <br />Mailing address City 5tate Zip Code County <br />2660 Cir►ic Center �ri�e Rose�iile MN 55193 Ramsey <br />Name of chief executi�e o�c�r {CEO) Day#ime phone number Email address <br />Bill Chandler <br />Attach a copy n# ONE of the foliowing for proof of nonprofit status, Check one. <br />Do not attach a safes tax exernpt status or fiederal ID emplayer numbers as they are not proof of nonproft status. <br />�Nonprofit Articles of lncorparation OR a current Gertificafe of Good Standing. <br />�on't hav� a copy? This certificate must be obtained each year from: <br />5ecre#ary of 5tate, Busir�ess Services Div., 98� Staie DfFice Building, St. Paul, MR! 55t55 Phane: 65�-296-28�3 <br />❑� IRS income tax exemption [5p1(c)] letter in yaur organiza#ion's name. <br />Dan't have a cnpy? To obtain a copy of your federal incame tax exempt lefter, have an nrganization officer <br />contact the IR5 a# 877-829-55�0. <br />�!RS - Affi[iate of nationat, statewide, or interna�ior�a{ parent nonprofit organizati4n (charterj <br />f� your organizatian falls under a parent organization, a4tach copies of both of the folbwing: <br />a. IRS letter showing your parent organization is a nonprafii 501{c) organization with a group ruling, ancf <br />b. the charter or letter from your parent arganization recogr�izing yot�r organization as a subordinate. <br />� IR5 - proof previously submitted to Gambling Contro[ Soard <br />If you pre�iousfy subrnitted proof of nonprofit status trarn the IRS, no attachment is required. <br />GAMBLING PRE�AISES INF'ORMATI�IV <br />Name of premises where gambling aetivi#y wiit be canducted (for raffles, list the site w�,ere the drawing will take ptace) <br />Roseville Fire Statian #1 <br />Address {do not use PO box) City <br />2T01 Nor�h �,exington Roseville <br />�ate(s) of activi#y (for raf#les, indicate #he date of tF€e drawing) <br />Zip Code County <br />nAN Ramsey <br />inday October 4, 2009 <br />,k the box or boxes that indicate the type of gambArtg activity your organization will conduct: <br />� Bingo* � Raf#les �i'addlewheels` � Pull-Tabs* �Tipbaards�° <br />* Ga€€�blir�g equipc�ent for p�ll-tabs, bingo paper, tipboards, and <br />paddEewheels must be obtained from a distributor ficensed by the <br />GambEing Control Board. EXCEPTION: Bir�go hard cards and bingo <br />n�mber selection de�ices may be borrowed from another organization <br />authorized to conduct bingo. <br />Also compl�te <br />Page 2 of this form. <br />Fill-in & Print Form <br />To find a lieensed distributor, ga to www.gcb.state.mr�.us and click o� List Reset Form <br />of Lic�nsed Distributors, or calE 651-639-4076. <br />