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Minnesota Lawful Gambling <br />LG240B Application to Conduct Excluded Bingo <br />3/11 <br />Page 1 of 2 <br />No fee <br />ORGANIZATION INFORMATION <br />Organization name <br />Knights of Columbus Council #14984 <br />Previous gambling permit number <br />Minnesota tax ID number, if any <br />Federal employer ID number, if any <br />27-2207603 <br />Type of nonprofit oraanization. Check CV) one. <br />Other nonprofit organization <br />_I ✓ <br />Fraternal _I _ _, Religious Veterans <br />Mailing address <br />7101 143rd Ave NW - Suite G <br />City <br />Ramsey <br />State Zip Code <br />MN 55303 <br />County <br />Anoka <br />ATTACH <br />A COPY OF ONE OF THE FOLLOWING <br />FOR PROOF OF NONPROFIT STATUS <br />* Do <br />not attach a sales tax exempt status or federal ID employer number as <br />Articles of Incorporation OR a current Certificate of Good Standing. <br />Don't have a copy? This certificate must be obtained each year from: <br />Secretary of State, Business Services Div., 180 State Office Building, St. <br />Revenue Service - IRS income tax exemption [501(c)] letter in <br />Don't have a copy? To obtain a copy of your federal income tax exempt <br />contact the IRS at 877-829-5500. <br />Revenue Service - Affiliate of national, statewide, or international <br />your organization falls under a parent organization, attach copies of <br />a. IRS letter showing your parent organization is a nonprofit 501(c) organization <br />b. the charter or letter from your parent organization recognizing your <br />they are not proof of nonprofit <br />Paul, MN 55155 Phone: <br />your organization's name. <br />letter, have an organization <br />parent nonprofit organization <br />both of the following: <br />status. <br />651-296-2803 <br />officer <br />(charter) <br />ruling, and <br />I,.- Nonprofit <br />IInternal <br />I _Internal <br />If <br />with a group <br />organization as a subordinate. <br />EXCLUDED BINGO ACTIVITY <br />1. No <br />2. The proposed <br />nYes Has your organization held a bingo <br />If yes, list the dates when bingo was <br />bingo event for which we are applying <br />of four or fewer bingo events held this year. <br />OR <br />up to 12 consecutive days in connection <br />county fair. Dates <br />event in the <br />conducted <br />will be: <br />Dates 4/9/11 <br />current calendar year? <br />5/21/11 9/17/11 10/15/11 <br />I_! .i one <br />with a: <br />Daytime phone 651-291-4415 <br />I_ conducted <br />3. Person <br />4. Name <br />5. Premises <br />6. City Ramsey <br />civic celebration. Dates <br />Minnesota state fair. Dates <br />in charge of bingo event Deacon Randy Bauer <br />of premises where bingo will be conducted Church of St Katharine Drexel <br />street address 7101 143rd Ave NW - Suite G <br />If township, name <br />of township <br />County Anoka <br />Bingo hard cards and bingo number selection devices may be borrowed from another organization <br />authorized to conduct bingo. Otherwise, bingo hard cards, bingo p aper, and bingo number selection <br />devices must be purchased from a distributor licensed by the Gambling Control Board. To find a licensed <br />distributor, go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. <br />Be sure to complete page 2 <br />