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Minnesota Lawful Gambling Page 1 of 2 <br />LG240B - Application to Conduct Excluded Bingo (No fee) 8/00 <br />If your organization has been licensed or exempted in the current calendar year, you are not eligible to apply for excluded bingo. <br />Organization Information Previous authorization number, if any <br />•(Org_ anization Name (`(�(as it appears on d�o�c*xi entarion flied with Minnesota Secretary of ` Statee or Internal Revenue Service) <br />e.,(1Y\�g.M\ \O\ 1 `�( l �-)\ �L.;�` ��P ! 1.—� \� 5.. 4 ) .\\(\v\ <br />Street <br />City <br />\. --,\X\Q \__t f1. <br />State <br />Zip code <br />\y <br />County <br />a �c <br />Type of nonprofit organization (check one): <br />0 Fraternal 0 Veteran <br />0 Religious j-etiier nonprofit <br />Type of proof of nonprofit - attach a copy (see instructions): <br />organization <br />Secretary of State's Office <br />(charter) <br />IN Certificate of Good Standing - Minnesota <br />0 Internal Revenue Service <br />Iffliate of parent nonprofit organization <br />Excluded Bingo Activity information <br />Has your organization held a bingo event in the current <br />No_,e------ Yes If yes, list the <br />year? <br />dates that bingo was conducted <br />bingo events held this year. <br />__ <br />_?'i <br />The bingo event will be one of four or fewer <br />Date(s) of bingo event(s) \ .(-NACll�) <br />\ I\fi IMM- �M <br />__. 1 <br />-OR - v <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) bingo <br />_ .,, .,— __,... , ,_, __ <br />— of event <br />Civic Celebration - Date(s) of bingo event <br />Name of person In charge of the bingo event -1Z---)0, <br />cmY rL ' --- <br />Daytime Phone (1 ) ,1kD - �`]e6t,Q <br />Premises Where Excluded Bingo Will Be Conducted <br />Name of premises rr ,n,S \\ '�_ <br />�G -M , \ ��C,1 C\\U L -(al\Ut \ <br />Street address <br />L\ VYN e1 A- <br />City or township Coun <br />Be sure to complete page 2 <br />