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. Minnesota Lawful Gambling LG240R Application to Conduct Excluded Raffle (No fee) 06/03 . If your organization has been Iicensec;l or exempted in the ~urrent calendar year, you are not eligible to apply for excluded raffle. Organization Information Previous authorization number, jf any ry of State or Internal Revenue Service) Street 3..:1 t/ S- City vi , I tH2..trej/ N i 1/ S Type of nonprofit organization (check one) o Fraternal D Veteran ~ ReligiQus 0 Other nonprofit organization Type of proof of nonprofit - attach a copy (see instructions): D Certificate of Good Standing .- Minnesota Secretary of State's Office ~ Internal Revenue Service D Affiliate of Parent nonprofit organization (charter) Excluded Raffle Activi Information Dale ofraffle drawing --L/--!--'---l- Nameofthe person in charyeofraffle Total marketvalueofraffleprizes $ (;)00. 6-0 (The value of all raffle prizes in a calendar year may not exceed $1500.) Phonel Ij,r-f I </'i'l- SI+ iffp Premises Where Excluded, Raffle Will Be Conducted Name of Premises . .::r$7/ L The infonnation provided in this applica . mplete and accurate to Ihe best of myknowledgc. Chief executive officer's signatu ~ Name {please print} Phone number ~t.~~.3t.-rf Oat. '1 /L2.JQd ThisfonnW1] be made available in aIlemativefonnat O.e. targe prin~ Braille) upon request The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to detennine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right 10 refuse 10 supply the infOlmation requested; however, it you refuse to supply this information, the Board may not be able to detennine your qualifications and, as a consequence, may refuse to issueyou an authorization. If you supply the infonnation requested, the Board will be able to process your application. Your name and your organization's name and address will be public information when received by the Board, All the other information that you provide win be private data about you until the Board issues your permit or authorization. When the Board issues your authorization. all of the infonnation that you have provided to the Board in the process of applying for your authorization will become public. If the Board does not issue you an authorization, all the information you have provided inthe process of applying for an authorization remains private. with the exception of your name and and your organization's name and address which win remain public. Private data about you are available only to the following: Board members; staff of the Board whose workassignment requires thatthey have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota' Commissioners of Administration. Finance, and Revenue; the Minnesota LegislativeAuditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agendes thatare spedficaUy authorized by state or federal law to have access to the information; individuals and agendes for which law or legal order authorizes a new use or sharing of infonnation after this Notice was given; and anyone with your oonsent . Mail Application and Attachment(s) Send the completed application and a copy of your proof of nonprofit status at least 30 days prior to the activity date to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113