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LG24OB <br />(R.v.1/21/93 <br />Minnesota Lawful Gambling <br />Application for Authorization to Conduct Excluded Bingo <br />Part 1 of 2 <br />(ff your organization has been licensed or exempted in the <br />current calendar year, you are not eligible to apply for excluded bingo) <br />Fill in the unshaded areas of this application and send it to the <br />Gambling Control Board at least 30 days prior to the activity. <br />ganizatton %foci a> ort <br />Organization <br />L /,gun Zi4 /4-S s L E"/17 <br />Street <br />/)9/1-14) <br />St" <br />Activity <br />City / <br />State Zip code <br />Type of nonprofit organization (check on8: <br />❑ Fratemal <br />❑ Religious (st Other nonprofit organization <br />Veteran <br />Type of proof of nonprofit status attached (check one): <br />Certificate of Good Standing - Minnesota Secretary of State's Office <br />D] Internal Revenue Service <br />[) Affiliate of Parent nonprofit organization (charter) <br />c�1 <br />orm; <br />.............. <br />Has your organization held a bingo event in the current calendar year? No <br />If yes, list the dates that bingo was conducted <br />Check one: <br />EIThe bingo event will be one of four or fewer bingo events your organization will hold this year. <br />Date(s) of bingo event: /71 hR e H A a, / 9 9( 4. ,v d ,(J L/ . / Y94, <br />Yes ❑ <br />OR <br />❑ The bingo event will be conducted (up to 12 consecutive days) in connection with a: <br />County Fair - Date(s) of bingo event <br />State Fair - Date(s) of bingo event <br />Civic Celebration - Date(s) of bingo event <br />Print the name of the person in charge of the bingo event <br />4-T •P/9 Ti4 /D6 e✓ <br />.:. ... .... <br />uctC <br />Name of premises L / Vo L,¢ / or4 `gym 43,G) <br />Daytime Phone <br />(40 /A) 7/c e, <br />Street Address <br />City <br />L /,VD <br />OR <br />�fl-Rai <br />County and Township <br />(Be sure to complete Part 2) <br />White - Original <br />Yslow -Board <br />