09-25-2013 Council Agenda - Laserfiche WebLink

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MINNESOTA LAWFUL GAMBLING LG240B Application to Conduct Excluded Bingo 6/13 Page 1 of 2 No Fee ORGANIZATION INFORMATION Organization name Previous gambling permit number Saint John's Church of Little Canada X13- 62005 -12 -002 Minnesota tax ID number, if any Federal employer ID number (FEIN), if any ES23330 41- 0781158 Type of nonprofit organization. Check one. Fraternal x Religious Veterans Other nonprofit organization Mailing address City State Zip code County 380 Little Canada Road Little Canada MN 55117 Ramsey Name of chief executive officer (CEO) Daytime phone number E -mail address Rev. Thomas Balluff 651 484 -2708 pastor @stjohnsoflc.org NONPROFIT STATUS Attach a copy of ONE of the following for proof of nonprofit status. Nonprofit Articles of Incorporation OR a current Certificate of Good Standing. Don't have a copy? This certificate must be obtained each year from: Secretary of State, Business Services Div,, 60 Empire Drive, Suite 100, St. Paul, MN 55103 Phone: 651- 296 -2803 ,,., _ IRS income tax exemption [501(c)] letter in your organization's name. Don't have a copy? To obtain a copy of your federal Income tax exempt letter, have an organization officer contact the IRS at 877- 829 -5500, IRS - Affiliate of national, statewide, or international nonprofit organization parent [charter] If your organization falls under a parent organization, attach copies of both of the following: a. IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling, and b, the charter or letter from your parent organization recognizing your organization as a subordinate. EXCLUDED BINGO ACTIVITY 1. X No Yes Has your organization held a bingo event In the current calendar year? If yes, list the dates when bingo was conducted. 2, The proposed bingo event will be: X one of four or fewer bingo events held this year. Dates 10 -27 -13 and 11 -24 -13 OR conducted on up to 12 consecutive days in connection with a: _ county fair. Dates _ civic celebration. Dates ___. Minnesota state fair. Dates 3. Person in charge of bingo event Rev. Thomas Balluff Daytime phone 651 484 -2708 4. Name of premises where bingo will be conducted school gymnasium 5. Premises street address 380 Little Canada Road 6, City Little Canada If township, township name County Ramsey Bingo hard cards and bingo number selection devices may be borrowed from another organization authorized to conduct bingo. Otherwise, bingo hard cards, bingo paper, and bingo number selection devices must be obtained from a distributor licensed by the Minnesota Gambling Control Board. To find a licensed distributor, go to www.geb.state.mn,us and dick on Distributors under the WHO'S WHO? LIST OF LICENSEES, or call 651- 639 -4000, Be sure to complete page 2