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CCP 07-31-2000
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CCP 07-31-2000
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<br />.. <br /> <br />e <br /> <br />e <br /> <br />e <br /> <br />Minnesota Lawful Gambling <br />Application to Conduct Excluded Raffle - LG240R <br /> <br />If your organization has been licensed or exempted in the current calendar year, you are not'lligiple toapply fOrex91uded raffle. <br />Organization Information <br />Organization Name <br />Trinit Lutheran Of Lake Joha <br />Street <br /> <br />2 ~1 <br /> <br />3/99 <br /> <br />a <br /> <br />FOR BOARD USE ONLY <br />Proof <br />10 sO C 0 <br />00 NO NAO <br />Other Activity <br /> <br /> <br />City County <br /> <br />Arden Hills Ramsey <br /> <br />Type of nonprofit organization (check one): <br />D Fraternal D Veteran <br />P'I Religious D Other nonprofit organization <br /> <br />Type of proof of nonprofit - attach a copy (see instructions): <br />D Certificate of Good Standing - Minnesota Secretary of State's Office <br />J8;J Internal Revenue Service Lf~ f<:,.{ In iY\ l<~o" tI.{ S'1 noJ 7scs>K <br />D Affiliate of Parent nonprofit organization (charter) <br /> <br />StatelZi p <br />55112 <br /> <br />MN <br /> <br />Excluded Raffle Activity Information <br /> <br />Date of raffle drawing <br /> <br />I nn <br /> <br />Total market value ofraffle prizes $ '7"" "" <br />(The value of all raffle prizes in a year may not exceed $750.) <br /> <br />,Johnson Phone ( fi'il )fiii 1 Rql <br /> <br />q f q <br /> <br />Name of the person in charge of raffle Pat r i cia <br /> <br />Premises Where Excluded Raffle Will Be Conducted <br />Name of Premises <br /> <br />3245 New Bri hton Rd. <br />Street Address (do not use PO box) <br /> <br />d <br /> <br />City <br /> <br /> <br />Chief Executive Officer's Signature <br />The information provided in this appli . complete and accura <br /> <br />Chief Executive Office~s Signature~ <br /> <br />Name (please print) --Le.e.. ~, Sf-e~.... 5 <br /> <br />Hills M <br /> <br /> <br />County <br /> <br /> <br />Township <br /> <br /> <br />Mail Application and Attachment(s) <br />Send the completed application and a copy of your proof of <br />nonprofit status at least 30 days prior to the activity date to: <br />Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville, MN 55113 <br /> <br />This form will be made available in alternative format (Le. large print, <br />Braille) upon request. The infonnation requested on this form (and <br />any attachments) will be used by the Gambling Control Board (Board) <br />to determine your qualifications to be involved in lawful gambling <br />activities in Minnesota. You have the right to refuse to supply the <br />information requested; however, if you refuse to supply this information, <br />the Board may not be able to determine your qualifications and; as a <br />consequence, may refuse to issue you an authorization. If you supply <br />the information requested, the Board will be able to process your <br />application. <br />Your name and your organization's name and address will be public <br />information when received by the Board. All the other information that <br />you provide will be private data about you until the Board issues your <br />permit or authorization. When the Board issues your authorization, all <br />of the information that you have provided to the Board in the process <br /> <br />st of my knowledge. <br /> <br />Date 7 123 I Cl() <br /> <br />AcknowledgmentofGambling Control Board <br />Your request to conduct excluded raffle has been received <br />and is acknowledged by the Gambling Control Board. <br />Acknowledged by: <br /> <br />Date_f_'_ <br /> <br />Licensing Specialist <br /> <br />of applying for your authorization will become public. If the Board <br />does not issue you an authorization, all the information you have <br />provided in the process of applying for an authorization remains private, <br />with the exception of your name and and your organization's name <br />and address 'which will remain public. <br /> <br />Private data about you are available only to the following: Board <br />members, staff of the Board whose work assignment requires that <br />they have access to the information; the Minnesota Department of <br />Public Safety; the Minnesota Attorney General; the Minnesota <br />Commissioners of Administration, Finance, and Revenue; the <br />Minnesota Legislative Auditor, national and intemational gambling <br />regulatory agencies; anyone pursuant to court order: other individuals <br />and agencies that are specifically authorized by state or federal law <br />to have access to the information; individuals and agencies for which <br />law or legal order authorizes a new use or sharing of information <br />after this Notice was given; and anyone with your consent. <br />
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