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5/24 <br />Page 1 of 2 <br />MINNESOTA LAWFUL GAMBLING <br />LG240B Application to Conduct Excluded Bingo No Fee <br />ORGANIZATION INFORMATION <br />Organization Previous Gambling <br />Name: ________________________________________________________ Permit Number: ____________________________ <br />Minnesota Tax ID Federal Employer ID <br />Number, if any: ______________________________________ Number (FEIN), if any: ________________________________ <br />Mailing <br />Address: _______________________________________________________________________________________________ <br />City: ____________________________________ State: _________ Zip: __________ County: ___________________________ <br />Name of Chief Executive Officer (CEO): ________________________________________________________________________ <br />NONPROFIT STATUS <br />Type of Nonprofit Organization (check one): <br />____ Fraternal ____ Religious ____ Veterans ____ Other Nonprofit Organization <br />Attach a copy of at least one of the following showing proof of nonprofit status: <br />(DO NOT attach a sales tax exempt status or federal employer ID number, as they are not proof of nonprofit status.) <br />____ Current calendar year Certificate of Good Standing <br />Don’t have a copy? This certificate must be obtained each year from: <br />MN Secretary of State, Business Services Division <br />60 Empire Drive, Suite 100 <br />St. Paul, MN 55103 <br />____ Internal Revenue Service-IRS income tax exemption 501(c) letter in your organization’s name <br />Don’t have a copy? Obtain a copy of your federal income tax exempt letter by having an organization officer contact <br />the IRS at 877-829-5500. <br />____ Internal Revenue Service-Affiliate of national, statewide, or international parent nonprofit organization (charter) <br />If your organization falls under a parent organization, attach copies of both of the following: <br />1.IRS letter showing your parent organization is a nonprofit 501(c) organization with a group ruling; and <br />2.the charter or letter from your parent organization recognizing your organization as a subordinate. <br />EXCLUDED BINGO ACTIVITY <br />Has your organization held a bingo event in the current calendar year? ____ Yes ____ No <br />If yes, list the dates when bingo was conducted: ______________________________________ <br />The proposed bingo event will be: <br />____ one of four or fewer bingo events held this year. Dates: __________________________________________ <br />-OR- <br />____ conducted on up to 12 consecutive days in connection with a: <br />___ county fair Dates: _______________________________________________________________ <br />___ civic celebration Dates: _______________________________________________________________ <br />___ Minnesota State Fair Dates: _______________________________________________________________ <br />Person in charge of bingo event: _________________________________________ Daytime Phone: _______________________ <br />Name of premises where bingo will be conducted: ________________________________________________________________ <br />Premises street address: ____________________________________________________________________________________ <br />City: __________________________ If township, township name: _______________________ County: ___________________ <br />Secretary of State website, phone numbers: <br />www.sos.state.mn.us <br />651-296-2803, or toll free 1-877-551-6767 <br />Email permit to (if other than the CEO): ______________________________________________________________________ Email permit to (if other than the CEO): _______________________________________________________________________ <br />(permit will be emailed to this email address unless otherwise indicated below) <br />CEO Daytime Phone: ______________________ CEO Email: _______________________________________________________