Agenda - Council - 07/13/2010 - Laserfiche WebLink

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_ . _ ..... Page 1 of 2 2/10 runncavua ~awru. vau.un.'y Application fee for each event LG220 Application for Exempt Permit Ifa lication ostmarked or received: An exempt permit may be issued to a nonprofit organization that: ~ less than 30 days before the event more than 30 days before the event - conducts lawful gambling on five or fewer days, and $100 . $50 -awards less than $50,000 in prizes during a calendar year. ORGANIZATION INFORMATION check# ~ h0.."~ Organization name Previous gambling permit number c.~c-K 5 I.L,J t~i n i T ~: i'~ ait+l ~~EY~L _ - O Type of nonproft organization. Check one. Fraternal ~ Religious ~ Veterans dOther nonprofit organization Mailing address City State Zip Cade County b~ 5 V 6t-r1 'L ~1 ~ r~Lt} Name of chief exec tive officer (CEO) Daytime phone number Email address ~o ~ c „6 w (a i ~ `i 6' `Fo $ SJ CG r Ct..rCa ~. >\~ Attach a copy of ONE of the following for proof of nonprofit status. Check one. Do not attach a sales tax exempt status or federal ID employer numbers 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 ~RS 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. IRS - AfFliate 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 nonproft 501(c) organization with a group ruling, and b. the charter or letter from your parent organization recognizing your organization as a subordinate. IRS -proof previously submitted to Gambling ConVOI Board If you previously submitted proof of nonprofit status from the IRS, no attachment is required. GAMBLING PREMISES INFORMATION Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) :.~ J- a wi " F ity Zip Code County C Address (do not use PO box) / J `~ ~ ~+. J u a O O IC t^ 5 D C. Date(s) of activity (for raffles, indicate the date of the drawing) O heck the box or boxes hat indicate the type of gambling activity your organization will conduct: Bingo'[~taffles Paddlewheels' ^Puli-Tabs' ^Tipboards" * Gambling equipment for pull-tabs, bingo paper, tipboards, and Also complete paddlewheels must be obtained from a distributor licensed by the pa e 2 of this form 9 . Gambling Control Board. EXCEPTION: Bingo hard Ards and bingo number selection devices may be borrowed from another organization authorized to conduct bingo. Print Form To find a licensed distributor, go to www.gcb.state.mn.usond click on List Reset Form of Licensed Distributors, or call 651-639-4076.