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11/20/2012 12:12 3202598719 <br />MINNESOTA LAWFUL GAMBLING <br />ra, felr'Ezelnn ®� Pe�c�t <br />FEDEX OFFICE <br />PAGE 02/03 <br />6/12 Page 1 of 2 <br />An exempt permit; may be issued to a nonprofit organization that: <br />- conducts lawful gambling cn five or fewer days, and <br />- awards less than $50,000 in prizes during a calendar year. <br />If total prize value for the year will be $1,500 or less, contact <br />the licensing specialist assigried to your county, <br />Application fee <br />If , f • ion f • - •. • ece v-1 <br />less than 30 days <br />before the event <br />$3.00 <br />more than 30 days <br />before the event <br />$50 <br />;O'R'GANIZATION INFORMATION <br />Organization n e <br />Previous gambling permit number <br />Minnesota tax ID number, f any Federal employer ID number (FEIN), if any <br />zi, " (4) 01,'7 <br />T a of nonprofit organisation. Check one. <br />Fraternal <br />.,Veterans <br />nonprofit organization <br />_keligious .__Other <br />Ma' <br />ing address City State Zlp code County <br />Data. tvi:,,J 5 Arn.S <br />Name of chief executive off cep [CEO] Daytime phone number E -mail address <br />! Z. — 3116 \N SQstkel e °►a c 1. <br />,___ _____\ to a <br />NONPROFIT STATU.S e <br />'O' <br />Att <br />ch a copy of ONE of the following for proof of nonprofit status. <br />Nonprofit. Articles i)f 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 1001, 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 officer contact <br />the IRS at 877 - 829.5500. <br />IRS - Affiliate of nz tional, 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 le:ter from your parent organization recognizing your organization as a subordinate, <br />',GA'M:BLING;MI EM']SES' NFORMA7.I'ON <br />Name of premises where th J;gambling event will be con cted. For raffles, lis, the site where the drawing will take place. <br />Address [do not use PO box' /`i(o 1+-'Q- y or to nshlp Zip code <br />! /'�' County �`�/ <br />01 , -, .... .... J ,. A I' , S 5„ V BO' �L Dole-..q_ <br />A I <br />Date[s] of activity. For raffil:s, indicate the date of the drawing. <br />121311 ►7.--- <br />Check each type of gamblinc activity that your organization will conduct. <br />Ra•fle Paddlewheels* Pull -tabs* Tipboards* <br />Bingo* <br />*Gambling equipment for bingo paper, paddlewheels, pull -tabs, and tlpboards must be obtained from a distributor <br />licensed by the Minnesota Gambling Control Board. EXCEPTION: Bingo heard cards and bingo number selection devices <br />may be borrowed from another organization authorized to conduct bingo. <br />To find a licensed distributor, go to www.gcb.stateann.us and click on 17istributors under <br />the WHO'S WHO? LIST OF LICENSEES, or call 651 -639 -4000. <br />11/20/2012 12:12 3202598719 <br />MINNESOTA LAWFUL GAMBLING <br />ra, felr'Ezelnn ®� Pe�c�t <br />FEDEX OFFICE <br />PAGE 02/03 <br />6/12 Page 1 of 2 <br />