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MINNESOTA LAWFUL GAMBLING
<br />LG240B Application to Conduct Excluded Bingo
<br />6/13 Page 1 of 2
<br />No Fee
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<br />Minnesota tax ID number, If any Federal employer ID number (FEIN), if any
<br />8702087 20-2429058
<br />Type of nonprofit organization. Check one,
<br />Fraternal X Religious Veterans Other nonprofit organization
<br />Mailing address City State Zip code County
<br />7101 143rd Ave NW -Ste G Ramsey MN 55303 Anoka
<br />Name of chief executive officer [CEO] Daytime phone number E-mail address
<br />Deacon Randy Bauer (763) 400-7203 randy@sjtw.net
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<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 />IRS - 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,
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<br />1, x No Yes Has your organization held a bingo event in the current calendar year?
<br />If yes, list the dates when bingo was conducted,
<br />2, The proposed bingo event will be:
<br />X one of four or fewer bingo events held this year. Dates �f3/14
<br />OR
<br />conducted on up to 12 consecutive days in connection with a:
<br />county fair, Dates
<br />civic celebration, Dates
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<br />Minnesota state fair. Dates
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<br />3, Person in charge of bingo event Deacon Randy Bauer Daytime phone 763-400-7203
<br />4. Name of premises where bingo will be conducted St Katharine Drexel
<br />5, Premises street address 7101 143rd Ave NW - Suite G
<br />6, 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 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 />651-539-1900, Be sure to complete page 2
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