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MINNESOTA LAWFUL GAMBLING <br />LG240B Application to Conduct Excluded Bingo <br />0�2CNA31"OMNFOR;r!1��1�`�p` <br />Organization name <br />)r- <br />6/13 Page 1 of 2 <br />No Fee <br />Previous 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 Religious <br />Mailing address <br />7101 143rd Ave NW - Suite G <br />Veterans Other nonprofit organization <br />Ramsey <br />Name of chief executive officer [CEO] <br />Deacon Randy Bauer <br />NON <br />City <br />State <br />MN <br />Daytime phone number <br />(763) 400-7203 <br />Zip code County <br />55303 Anoka <br />E-mail address <br />randvpa sjtw.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 organlzatlon <br />officer contact the IRS at 877-829-.5500, <br />IRS - Affiliate of national, statewide, or international parent nonprofit organization [Charter] <br />If your organlzatlon 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) organlzatlon with a group ruling, and <br />b. the charter or letter from <br />yyyour <br />`parent organlzatlon recognizing your organization as a subordinate, <br />GXVLUb�d�i��' di; lIl\/Y i• <br />.... ., ..-. - .. .i <br />1, x <br />No Yes Has your organlzatlon 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 />one of four or fewer bingo events held this year, Dates 2/21/15, 4/25/15 <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 O 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 />