CCP 10-09-2001 - Laserfiche WebLink

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Minnesota Lawful Gambling Page 1 of2 3/01 . LG220 - Application for Exempt Permit Fee - $25 I For t10ard Use Only Fee Paid Organization Information Check No. Organization name Previous lawful gambling exemption number THE CATHOLIC AID ASSOCIATION Street City State/Zip Code County 3499 N. LEXINGTON AVE. ARDEN HILLS MN 55126 RAMSEY Name of chief executive officer (CEO) First name Last name Daytime phone number of CEO MICHAEL F. MCGOVERN 651-490-0170 Name of treasurer Daytime phone number of First name Last name treasu rer: DENNIS L. OLSON 651 490-0170 Type of Nonprofit Organization Check the box that best describes your organization: [Jg Fraternal D Religious D Veteran D Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: IX] 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 affiiiate of a parent nonprofit organization D Proof previously submitted and on fiie with the Gambling Control Board . Gamblina Premises Information Name of premises where gambiing activity will be conducted (for raffles. list the site where the drawing will take place) CATHOLIC AID ASSOCIATION HOME OFFICE Address (do not use PO box) City StatelZip Code County 3499 N. LEXINGTON AVE ARDEN HILLS MN 55126 RAMSEY Date(s) of activity (for raffles. indicate the date of the drawing) SEE ATTACHED _-=l-":/.'~OA Check the box or boxes that indicate the type of gambling activity your organization will be conducting: D "Bingo [Xl Raffles (cash prizes may not exceed $12,000) D "Paddlewheels D "Pul~ Tabs o "Tipboards "Equipment for these activities must be obtained from a licensed distributor. This form will be made available in aitemative 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 reluse to supply the information requested; however, ifyou reluseto supply this information. the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will 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 information that you provide will be private data about you until the Board issues your permit. When the Board issues your permit. all of the information that you have provided to the Board in the process of applying for your permit will become public. If the Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are available only to thefollow.ng: Board members, statfofthe Board whose wor1< 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 LegislatWe Auditor, national and intemational 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 0; legal order authorizes a new use or sharing of information alter this Notice was given; and anyone with your consent. . .