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MINNESOTA LAWFUL GAMBLING <br />LG240B Application to Conduct Excluded Bingo <br />ORGANIZATION INFORMATION <br />Organization name <br />Saint John's Church of Little Canada <br />Minnesota tax ID number, if any <br />ES23330 <br />6/12 Page 1 of 2 <br />Previous gambling permit number <br />x- 62005 -11 -003 <br />Federal employer ID number (FEIN), if any <br />41- 0781158 <br />Type of nonprofit organization. Check one. <br />Fraternal I 1 veterans <br />Religious <br />IlOther nonprofit organization <br />Mailing address <br />380 Little Canada Road <br />City <br />Little Canada <br />State Zip code <br />MN 55117 <br />County <br />Ramsey <br />Name of chief executive officer [CEO] <br />Rev. David Kohner <br />NONPROFIT STATUS <br />Daytime phone number <br />651 484 -2708 • <br />E -mail address <br />dwkohner(d comcast.net <br />Attach a copy of ONE of the following for proof of nonprofit status. <br />n_ 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 />laIRS income tax exemption [5O1(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 />EXCLUDED BINGO ACTIVITY <br />1. [NA_ 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 />a one of four or fewer bingo events held this year. Dates <br />10 -28 -12 <br />OR <br />ELconducted on up to 12 consecutive days in connection with a: <br />d <br />I county fair. Dates <br />I I <br />civic celebration. Dates <br />Minnesota state fair. Dates <br />3. Person in charge of bingo event <br />Rev. David Kohner Daytime phone 651- 484 -2708 <br />4. Name of premises where bingo will be conducted <br />School Gymnasium <br />5. Premises street address 380 Little Canada Road <br />Little Canada County Ramsey <br />6. City If township, township name <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 Be <br />F sure to complete CENSEES, <br />call <br />page 2 <br />651- 639 -4000. <br />