CCP 02-26-2001 - Laserfiche WebLink

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Check No. Previous lawful gambling exemption number fu-Ioovi C>>J. tu.xc...., StalelZip Code NN . Minnesota Lawful Gambling LG220 - Application for Exempt Permit Organization Information Organization name \ (\(\~o-\iA SOU Street \\\,Jt ~ ~ I S'~ l\.udo..na. Name of chief executive officer (CEO) First name Mo.V-\L Name of treasurer Fp~~r ~~a Type of Nonprofit Organization City 'bt-. Pcu J\ Last name SA<X\ Fee - $25 Page 1 of 2 8/00 For oard Use n y Fee Paid County S-S-tCl Daytime phone number of CEO I\f:la- Check the box that best describes your organization: D Fraternal D Religious . D Veteran ~ Other nonprofrt organization Check the box that indicates the type of proof your organization attached to this application: D IRS letter indicating income tax exempt status D Certificate of Good Standing from the Minnesota Secretary of State's Office . D A charter showing you are an affiliate of a parent nonprofit organization D Proof previously submitted and on file with the Gambling Control Board Gamblin Premises Information Name of premises where gambling activity will be conducted (for raffles, iist the sne where the drawing will take place) f,e.:; e,\ e.D\ Address (do not use PO box '~9DJ 5exhd (3(. \N <1(1 wi'^- 3-2.\-D\ Check the box or boxes that indicate the type of gambling activity your or9anization will be conducting: D OBingo MRaffles D oPaddlewheels DOPull-Tabs D oTipboards *Equipment for these activities must be obtained from a licensed distributor. This form will be made available in Your name and and your organization's a~ernative format (i.e. large print, Braille) name and address will be public informatbn upon request. The information requested when received by the Board. All the other on this form (and any attachments) will be information that you provide will be private used by the Gambling Control Board data about you until the Board issues your (Board) to detennine your qualifications to permit. When the Board issues your be involved in lawful gambling activities in permit, all of the information that you have Minnesota. You have the rightto refuse to provided to the Board in the process of supply the information requested: however, applying for your permit will become public. if you refuse to supply this information, the If the Board does not issue you a permit, Board may not be able to determine your all the information you have provided in the qualifications and, 85 a consequence, may process of applying for a permit remains refuse to issue you a permit. If you supply private, with the exception of your name the information requested, the Board will and your organization's name and address be able to process your application. which will remain public, Private data about you are available only to City Date(s) of activity (for raffles, indicate the date of the drawing) ~-ZD-{)~ Ii. 3-2\-{) . Slate/Zip Code County QCl'fflS the following: Board members, staff of the Board whose work assignment requires that they heve 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.