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Minnesota Lawful Gambling <br />Application to Conduct Excluded Bingo - LG240B <br />If your organization has been licensed or exempted in the current calendar year, you are not eligible to apply for excluded <br />bingo. <br />Organization Information <br />Organization Name (� <br />P. esN-� -e 'r\c� ( 0' L_L o re_(-, c)-- -To CL ai <br />Street <br />PO .Rey. s4c, <br />City State/Zip <br />( r c i S L P i r S M (4 SS o 1 1 <br />) <br />Type of nonprofit organization (check one): <br />❑ Fratemal p Veteran <br />❑ Religious 0 Other nonprofit organization <br />Type of proof of nonprofit - attach a copy (see instructions): <br />XCertificate of Good Standing - Minnesota Secretary of State's Office <br />❑ 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 year? <br />If yes, list the dates that bingo was conducted <br />Check one: <br />12/The bingo event will be one of four or fewer bingo events your organization will hold this year. <br />Date(s) of bingo event A pr-; k 30 Acton <br />No V <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 />Name of the person in charge of the bingo event <br />Premises Where Excluded Bingo Will Be Conducted <br />Daytime Phone <br />(ei)..)- 14 -gcn7 <br />Name of Premises <br />c — L9 E try. e r*o c <br />Street Address <br />City <br />County Township <br />Be sure to complete page 2 <br />Page 1 of 2 <br />10/98 <br />