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• <br />• <br />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 />3o 1 ) <br />Organization Name (as it appears on documentation filed with Minnesota Secretary of State or Internal Revenue Service) <br />FTA l Li nc L-Clf r`) �-�'-� tenni d M idcl le : �(_hr, 1 <br />Street <br />3961 Efry f <br />City <br />ho oK <br />State <br />M NI <br />Zip code <br />.a 50 6 9- <br />County <br />Ai')oK . <br />Type of nonprofit organization (check one): <br />organization <br />Secretary of State's Office <br />(charter) <br />• Fraternal Veteran <br />Religious Eg Other nonprofit <br />Type of proof of nonprofit - attach a copy (see instructions): <br />Certificate of Good Standing - Minnesota <br />Internal Revenue Service <br />El Affiliate of parent nonprofit organization <br />Excluded Bingo Activity Information <br />Has your organization held a bingo event in the current <br />Nod( Yes If yes, list the <br />year? <br />dates that bingo was conducted <br />bingo events held this year. <br />2 2.CY 1 <br />0 The bingo event will be one of four or fewer <br />Date(s) of bingo event(s) Rid!), Feh. <br />/, <br />-OR - <br />The bingo event will be conducted (up to 12 <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 />Name of person in charge of the bingo event Va_len <br />consecutive days) in connection with a: <br />6 +fide , (p TA Cr - j� res .) <br />Daytime Phone (NC�•'� -/ ) '7 2 - .5(1 2_ <br />a <br />Premises Where Excluded Bingo Will Be Conducted <br />Name of premises <br />C ?`)Wr1 ilia 1 MI,d (ile, ` ho j <br />Street address <br />399 Elm X17 <br />City or township County <br />Lino 14-kS Mt' Anoka_. <br />Be sure to complete page 2 <br />