CCP 02-22-1999 - Laserfiche WebLink

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'. .. e e e Page 1 of 2 For Board Use On 10/98 Fee PaKl Check No. Initials Received I I PreVious lawful gambling exemptiOn number )(s V;;:Jl S 9 StatelZip COdE! 55112 Minnesota Lawful Gambling Application for Exempt Permit - LG220 Organization Information Orgaiiizatjoll name St. Johqthe Baptist Street City 835 2nd Ave NW New Brighton, MN Name of chief executiVe officer (CEO) of organization First name Last name William Murtaugh Name of teaslJrer of organization. First name .. Last name County Ramse Daytime phone number of CEO: ( 651 )633-8333 D"ytlmephone number of treasurer: (651 ) 633-8333 Rob Type of Nonprofit Organization Check the box'that best describes your organization: o Fratemal 1ZI. Religious o Veteran 0 Other nonprofit organization Check the box that Indicates the type of proof your organization attached to this application: ,. D.... IRS letter indicating incOme tax exempt status o Certificate of Good Standing from the Minnesota Secretary of state's Office 0/ A charter Showing you arE! an affiliate of a parent nonprofit organization 0" . Proof previously submitted and on file with the Gambling Control Board .' Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles. list the site where the drawing will take place) Holiday Inn , Address (do not use PO box) City StateIZlp Code County 1201 W. County Rd E Arden Hills, MN 55112 Ramsev .Date(s) of activity (for .raflles.indicatethe date of the drawing) , .... Friday,. March 19, 1999 . Check the box or boxes that Indicate tM type ofllamblingactivity YQur .0rg~lzation will be conducting: o "BIngo t3JRaffteS o .PaddI~ls O.PulJ..Tabs . f8:I "Tipboards .Equipment forlhese activities must be obtaitied from a licenSed distribUtor. . . . .. This form will be made available in a1temative fonnat (Le.large print, BralIe) upon request. The infonnation 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 hS'Je 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 qualilicalions lIld. as a consequence. mayrefuse to issue you a permi!. If you supply the infonnation requested. the Board y,jll be able to process your application. Your name and and your organization's name and address will be public information When received by the Board; All the other infonnatiorl that you provide will be private data about you until the Board issues your permil.When the Board iSsUes your permit, aU of the information that you have provided to the Board in the process of applying for your parmI! will.become pUbl!c;lIthe Board does not issul1YOu a permit. .. all the Ihformation you have provided in the process of applying for a permi! remainS private. with the exc~ption of your name and your organization's name and address which will remain pubnc. Privaledata about you areavaUable only to the following: Board members, staff of the Board whose work assignment requiresthatthey have access to the information ; the Minnesota Department of Public safety; the. Minnesota AltonleyGenerel; the Minnesota Commissioners of Administration, finance. and Revenue;.the Minnesota Legislative Auditor. national and in~mational gambling. regulatory agencies: anyone pursuant to court order; other individuals and agencies that are specilicaIly 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 ofinfo.nnation.thls Notice wasgiven; and anyone with your consent.