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. LG240B <br />(Rev. 1/21/93) <br />Minnesota Lawful Gambling <br />Application for Authorization to Conduct Excluded Bingo <br />Part 1 of 2 <br />(If 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 />Organization Information <br />Organization <br />Street <br />/21A' / 7 - <br />FOR BOARD <br />Proof <br />ID s ❑ c 0 <br />0 ❑ N ❑ NA D' <br />Other Activity <br />City )/ � / / �� �/� ` State Zip code <br />Type of nonprofit organization (check one: <br />❑ Fraternal Veteran <br />❑ Religious 14 Other nonprofit organization <br />Type of proof of nonprofit status attached (check one): <br />Certificate of Good Standing - Minnesota Secretary of State's Office <br />O 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 current calendar year? No E Yes 0 <br />If yes, list the dates that bingo was conducted <br />Check one: <br />itjThe bingo event will be one of four or fewer bingo events your organization will hold this year. <br />Date(s) of bingo event: it 7 <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 />A7n4T�/9 f,9/A'/ <br />Premises where excluded bingo will be conducted <br />Daytime Phone <br />(( ice) <br />Name of premises <br />Street Address <br />City <br />White - Original <br />Yellow - Board <br />OR County and Township <br />(Be sure to complete Part 2) <br />