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MINNESOTA LAWFUL GAMBLING <br />LG240B Application to Conduct Excluded Bingo <br />6/12 Page 1 of 2 <br />ORGANIZATION INFORMATION <br />Organization name Previous gambling permit number <br />Saint John's Church of Little Canada x- 62005 -11 -003 <br />Minnesota tax ID number, if any Federal employer ID number (FEIN), if any <br />ES23330 41- 0781158 <br />Type of <br />nonprofit <br />Fraternal <br />organization. Check one. <br />r <br />Religious 1 Veterans r- nonprofit organization <br />Mailing address City State Zip code County <br />380 Little Canada Road Little Canada MN 55117 Ramsey <br />Name of chief executive officer [CEO] Daytime phone number E -mail address <br />Rev. David Kohner 651 484 -2708 dwkohner©comcast.net <br />NONPROFIT STATUS <br />Attach a <br />copy of ONE of the following for proof of nonprofit status. <br />Articles of Incorporation OR a current Certificate of Good Standing. <br />have a copy? This certificate must be obtained each year from: <br />of State, Business Services Div., 60 Empire Drive, Suite 100, St. Paul, MN 55103 <br />651- 296 -2803 <br />income tax exemption [501(c)] letter in your organization's name. <br />have a copy? To obtain a copy of your federal income tax exempt letter, have an organization <br />contact the IRS at 877 - 829 -5500. <br />- Affiliate of national, statewide, or international parent nonprofit organization [charter] <br />your organization falls under a parent organization, attach copies of both of the following: <br />IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and <br />the charter or letter from your parent organization recognizing your organization as a subordinate. <br />Nonprofit <br />Don't <br />Secretary <br />Phone: <br />IRS <br />Don't <br />officer <br />IRS <br />If <br />a. <br />b. <br />EXCLUDED BINGO ACTIVITY <br />1. II _ <br />2. The proposed <br />Eone <br />Elconducted <br />3. Person <br />4. Name <br />5. Premises <br />6. City Little <br />No <br />OR <br />1 _ Yes Has your organization held a bingo event in the current calendar year? <br />If yes, list the dates when bingo was conducted. <br />bingo event will be: <br />of four or fewer bingo events held this year. Dates 1 1 -18 -12 <br />on up to 12 consecutive days in connection with a: <br />county fair. Dates <br />civic celebration. Dates <br />Minnesota state fair. Dates <br />in <br />of <br />charge of bingo event Rev. David Kohner Daytime phone 651 484 -2708 <br />premises where bingo will be conducted school gymnasium <br />street address 380 Little Canada Road <br />Canada If township, township name County Ramsey <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- 639-4000. Be sure to complete page 2 <br />