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Page 1 of 2 1/11 <br />viiil"C„"" L_avviu: %JOW /1111 U <br />LG220 Application for Exempt Permit <br />An exempt permit may be issued to a nonprofit organization that: <br />- conducts lawful gambling on five or fewer days, and <br />- awards less than $50,000 in prizes during a calendar year. <br />Application fee for each event <br />If application postmarked or received: <br />less than 30 days <br />before the event <br />$100 <br />more than 30 days <br />before the event <br />$50 <br />ORGANIZATION INFORMATION Check <br /># $ <br />-- <br />Organization name Previous gambling permit number <br />Isanti Chapter of Mn. Deer Hunters K .._ ©_S- c{/O ,-_ // .— 00 <br />Type of nonprofit organization. Check one. <br />Fraternal Religious Veterans X Other nonprofit organization <br />Mailing address City State Zip Code County <br />205-1st Ave.East Cambridge MN 55008 Isanti <br />Name of chief executive officer (CEO) Daytime phone number J.. Email address <br />-L`- <br />John Erlandson 763-689-4992. - rye (G-a-e�' <br />Attach a copy of ONE of the following for proof of nonprofit status. <br />Check one. <br />Do not attach a sales tax exempt status or federal ID employer numbers as they <br />are not proof of <br />Paul, MN 55155 <br />letter, have an <br />(charter) <br />of the following: <br />nonprofit status. <br />Phone: 651-296-2803 <br />organization officer <br />group ruling, and <br />subordinate. <br />Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. <br />Don't have This certificate must be obtained each from: <br />a copy? year <br />Secretary of State, Business Services Div., 180 State Office Building, St. <br />X IRS income tax exemption [501(c)] letter in your organization's name. <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 />IRS - Affiliate of national, statewide, or international parent nonprofit organization <br />If your organization falls under a parent organization, attach copies of both <br />a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a <br />b. the charter or letter from your parent organization recognizing your organization as a <br />GAMBLING PREMISES INFORMATION <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />Armstrong Ranch/Game Fair <br />Address (do not use PO box) City Zip Code County <br />8404-161st Ave.NW `1(S' y 55303 Anoka <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />August 21, 2011 <br />Check the box or boxes that indicate the type of gambling activity your organization <br />will conduct: <br />Bingo* i Raffles Paddlewheels* ❑ Pull -Tabs* ❑Tipboards* <br />* Gambling equipment for pull -tabs, bingo paper, tipboards, and <br />paddlewheels must be obtained from a distributor licensed by the <br />Gambling Control Board. EXCEPTION: Bingo hard cards and bingo <br />number selection devices may be borrowed from another organization <br />authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.state.mn.us and click on List <br />of Licensed Distributors, or call 651-639-4000, <br />Also complete <br />Page 2 of this form. <br />Print Form <br />Reset Form <br />L.` f 0 <br />