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• <br />• <br />bit-- Zti-ZUI J 1 14 - �3 Y Ub L 1 NU LHKL5 <br />b51 'Jb2 2439 N.02 /0b <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 />.2)01`--(s) <br />Organization Name (es it appears on documentation filed with Minnesota Secretary of State or Internal Revenue Service) <br />V R ( : \--C -) ��- r \Nr, nlc kma\ ,c\ <br />Street <br />City <br />State <br />Zip code <br />County <br />Type of nonprofit organization (check one): <br />Fraternal Veteran <br />Religious Q- ofgier nonprofit organization <br />Type of proof of nonprofit - attach a copy (see Instructions): <br />Q Certificate of Good Standing - Minnesota Secretary of State's Office <br />Internal Revenue Service <br />fflllate of parent nonprofit organization (charter) <br />Excluded Bingo Activity Information <br />Has your organization held a bingo event In the current <br />No ✓ Yes If yes, list the <br />year? <br />dates that bingo was conducted <br />bingo events held this year. <br />tuo <br />Q----The bingo event will be one of four or fewer <br />Date(s) of bingo event(s) F\7( <br />I_ <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 <br />consecutive days) In connection with a: <br />/∎ \IVCCA\Cl T <br />Daytime Phone ( ) "1,5c6LO <br />Premises Where Excluded Bingo Will Be Conducted <br />Name of premises <br />Street address C-40--Q_A- <br />3CC\ \ v <br />City or township County <br />Be sure to complete page 2 <br />