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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 organization. Check one. <br />lid Fraternal i Religious 1111 Veterans I..: 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 763- 4Q0 -72Q3 canclaailwaet <br />NONPROFIT STATUS <br />Attach a copy of ONE of the following for proof of nonprofit status. <br />Nonprofit 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., 60 Empire Drive, Suite 100, St. Paul, MN 55103 <br />Phone: 651 - 296 -2803 <br />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 letter, have an organization <br />officer contact the IRS at 877-829-5500. <br />I IRS <br />- Affiliate of national, statewide, or international parent nonprofit organization [charter] <br />If your organization falls under a parent organization, attach copies of both of the following: <br />a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <br />b. the charter or letter from your parent organization recognizing your organization as a subordinate. <br />EXCLUDED BINGO ACTXVXTY <br />1 , <br />2. <br />3. <br />4. <br />5. <br />6. <br />_✓_ No ,T_; Yes Has your organization held a bingo event in the current calendar year? <br />If yes, list the dates when bingo was conducted. <br />The proposed bingo event will be: <br />Q one of four or fewer bingo events held this year. Dates 1/26/13, 4/20/13 <br />OR <br />conducted on up to 12 consecutive days In connection with a: <br />Fl county fair. Dates <br />I I civic celebration. Dates <br />Minnesota state fair. Dates <br />Person in charge of bingo event Deacon Randy Bauer Daytime phone 763 400 - 7203 <br />Name of premises where bingo will be conducted Church of St Katharine Drexel <br />Premises street address 7101 143rd Ave NW Suite G <br />City Ramsey If township, township name County Anoka <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 Ilcensed 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 />