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9 <br />Organization Information <br />Organization legal name Previous license or permit number, if any <br />Street / <br />po , g0 'r3V <br />City <br />A dV- <br />State <br />KM/ <br />Zip code <br />X5303 <br />- Minnesota Secretary <br />County <br />A-Ivog <br />of State's Office <br />Type of nonprofit organization (check one): <br />Fratemal Religious <br />Veterans EXI Other nonprofit organization <br />Type of proof of nonprofit - attach a copy (see instructions) <br />Nonprofit Articles of Incorporation or Certificate of Good Standing <br />Internal Revenue Service <br />Affiliate of parent nonprofit organization (charter) <br />Excluded Bingo Activity Information <br />Has your organization held a bingo event in the <br />No X Yes If yes, list the <br />current year? <br />dates that bingo was conducted <br />bingo events held this year. <br />The bingo event <br />Date(s) of <br />-OR - <br />/` The bingo event <br />County Fair - <br />State Fair - - --- <br />Civic Celebration <br />A civic celebration <br />govemment <br />Name of person in charge <br />Daytime phone 1 <br />will be one of four or fewer <br />bingo event(s) <br />will be conducted (up to 12 <br />- -- Date(s) of bingo event <br />-- Date(s) of bingo event <br />- Date(s) of bingo event <br />is defined as an <br />having jurisdiction over <br />of the bingo event <br />L --7 5 3 No <br />consecutive days) in connection with a: <br />l — 1 6 — 0 ! - <br />event conducted in Minnesota that is sponsored by a local unit of <br />the event. t� �,, \�- <br />�LrC- V. 2C,r <br />Bingo equipment (hard cards, bingo paper, and bingo ball selection device) must be purchased <br />from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to <br />www.gcb.state.mn.us and dick on List of Licensed Distributors. Or call 651- 639 -4000. <br />Premises Where Excluded Bingo Will Be Conducted <br />Name of premises <br />ref PC r 54 - e-..._ <br />Street address <br />- 7 55 LI 1 C4.10e d el= V- - <br />Cik or township Zip code County <br />5c11' 5 50 3 A-tio <br />Minnesota Lawful Gambling <br />LG240B Application to Conduct Excluded Bingo (No fee) <br />Page 1 of 2 <br />11/04 <br />Excluded bingo may be conducted by an organization that conducts 4 or fewer bingo occasions in a calendar year, or in connection <br />with a county fair, the state fair, or a civic celebration if it is conducted on 12 or fewer consecutive days in a calendar year. If your <br />or anization has been licensed or exemp in the current calendar year, you are not eligible to apply for excluded bingo. <br />