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Minnesota Lawful Gambling Application to Conduct Excluded Raffle - LG240R If your organization has been licensed or exempted in the current calendar year, you are not Elligible to apply for el<cluded raffle, Organization Information Organization Name Trinit Lutheran Of Lake Johann Street , . 3245 N ,( 2 II 3/99 StatelZip 55112 FOR BOARD USE ONLY Proof I 0 sO c 0 00 NO NAO Other Activity a~ Coo~ Arden Hills Ramse Type of nonprofit organization (check one): o Fraternal 0 Veteran P'I Religious 0 Other nonprofit organization Type of proof of nonprofit - attach a copy (see instructions): o Certificate of Good Standing - Minnesota Secretary of State's Office l8J Internal Revenue Service L'~f<;,.( In m \>s",,,,,-, S'1no" 7s"",J:C o Affiliate of Parent nonprofit organization (charter) MN Excluded Raffle Activity Information Oateofraffledrawing g / g , 00 Total market value of raffle prizes $ "7~n nn (The value of all raffle prizes in a year may not exceed $750.) Name of the person in charge of raffle patricia Johnson Phone I n"1 )n" 1 Rgl Premises Where Excluded Raffle Will Be Conducted Name of Premises . 3245 New Bri hton Rd. Street Address (do not use PO box) rden Hill M City Chief Executive Officer's Signature The information provided in this applic complete and accura Chief Executive Officer's signature'----"~ Name (please print) ~e-e_ ;::;-, Si-e-~ k 5 Coun~ Township 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 . This form will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however. if you refuse to supply this information, the Board may not be able to determine your qualifications and; as a consequence, may refuse to issue you an authorization. If you supply the information 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 will be private data about you until the Board issues your permit or authorization, When the Board issues your authorization, all of the information that you have provided to the Board in the process 5t of my knowiedge. Date 7 1~0c) AcknowledgmentofGamblingControl Board Your request to conduct excluded raffle has been received and is aCknowledged by the Gambling Control Board, Acknowledged by: Oate_'----1_ Licensing Specialist of applying for your authorization will become public. If the Board does not issue you an authorization. all the information you have provided in the process of applying for an authorization remains private, with the exception of your name and and your organization's name and address which will remain public. Private data about you are available only to the following: Board members~ staff of the Board whose work assignment requires that they 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 Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given: and anyone with your consent.