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MINNESOTA LAWFUL GAMBLING <br />LG240B Application to Conduct Excluded Bingo <br />XNF AY�O y <br />Organization name <br />6/13 Page 1 of 2 <br />No Fee <br />Prevlous gambling permit number <br />Minnesota tax ID number, If any Federal employer ID number (FEIN), if any <br />27-2207603 <br />Type of nonprofit organization. Check one, <br />x Fraternal <br />Religious Veterans Other nonprofit organization <br />Mailing address City <br />7101 143rd Ave NW - Suite G Ramsey <br />Name of chief executive officer [CEO] <br />Deacon Randy Bauer <br />;38 <br />State ZIp code <br />MN 55303 <br />Daytime phone number <br />4763) 400-7203 <br />County <br />Anoka <br />E-mail address <br />randy sitw.net <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. <br />ACtIVITY <br />1. No X Yes Has your organization held a bingo event In the current calendar year? <br />If yes, list the dates when bingo was conducted. 1/25/14, 5/3/14 <br />2. The proposed bingo event will be: <br />one of four or fewer bingo events held this year, Dates 11/8/14 <br />OR <br />conducted on up to 12 consecutive days in connection with a: <br />county fair. Dates <br />_ civic celebration. Dates <br />_ Minnesota state fair. Dates <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 Church of 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 <br />