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ORGANIZATION INFORMATION <br />Organization name Previous gambling permit number <br />Knights of Columbus Council #14984 XB - 92629 <br />Minnesota tax ID number, if any Federal employer ID number (FEIN), if any <br />27- 2207603 <br />Ty.e of nonprofit <br />Fraternal <br />organization. Check one. <br />,Religious Veterans ...._1 Other nonprofit organization <br />Mailing address City State Zip code County <br />7101 143rd Ave NW - Suite G Ramsey MN 55303 Anoka <br />Name of chief executive officer [CEO] Daytime phone number E-mail address <br />Deacon Randy Bauer Z63 -40.0 -7203 randy©sjtw.net <br />NONPROFIT STATUS <br />Attach a <br />r ___i_ Nonprofit <br />Don't <br />Secretary <br />Phone: <br />copy of ONE of the following for proof of nonprofit status. <br />Articles of Incorporation OR a current Certificate of Good Standing. <br />have a copy? This certificate must be obtained each year from: <br />of State, Business Services Div., 60 Empire Drive, Suite 100, St. Paul, MN 55103 <br />651 - 296 - 2803 <br />income tax exemption [501(c)] letter in your organization's name. <br />have a copy? To obtain a copy of your federal Income tax exempt letter, have an organization <br />contact the IRS at 877- 829 -5500. <br />- Affiliate of national, statewide, or international parent nonprofit organization [charter] <br />your organization falls under a parent organization, attach copies of both of the following: <br />IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <br />the charter or letter from your parent organization recognizing your organization as a subordinate. <br />IRS <br />Don't <br />officer <br />E IRS <br />If <br />a. <br />b, <br />EXCLUDED BINGO ACTIVITY <br />1._ <br />2, <br />3, <br />4. <br />5. <br />6. <br />No <br />one <br />OR <br />F'• <br />Yes Has your organization held a bingo event in the current calendar year? <br />If list the dates when bingo was conducted. 4/21/12. 5/19/12 <br />The proposed <br />bingo <br />of four <br />county <br />I civic <br />Minnesota <br />charge <br />premises <br />street <br />Y <br />yes, <br />event will be:. <br />fewer bingo events held this year. Dates 11 <br />✓_ <br />EL conducted <br />Person <br />Name <br />Premises <br />City Ramsey <br />or <br />on up to 12 consecutive days in connection with a: <br />fair. Dates <br />I <br />celebration, Dates <br />state fair. Dates <br />bingo event Deacon Rand Bauer Daytime phone 763- 400 -7203 <br />in <br />of <br />of <br />where bingo will be conducted Church of St Katharine Drexel <br />address 7101 143rd AVe NW _, Suite G <br />County Anoka <br />If township, township name Y <br />Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized <br />to conduct bingo. Otherwise, bingo hard cards, bingo paper, and bingo number selection devices must be obtained <br />from a distributor licensed by the Minnesota Gambling Control Board. To find a licensed distributor, go to <br />www.gcb.state.mn . us and click on Distributors under the WHO'S WHO? LIST OF LICENSEES, or call <br />651 - 639 - 4000.. Be sure to complete page 2 <br />MINNESOTA LAWFUL GAMBLING <br />LG240B Application to Conduct Excluded Bingo <br />6/12 Page 1 of 2 <br />