2006-06-14 CC Packet - Laserfiche WebLink

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Previous lawful gambling exemption number X- 1 f'{)oS State/Zip Code County MN 55038 Anoka Daytime phone.number of CEO: 651-429~7937 Daytime phone number of 115'- 4ZIJJ - S3J ftJ Minnesota Lawful Gambling Application for Exempt Permit - LG220 Organization In,formation Organization name Church of St. Genevieve Street City Centerville 7087 Goiffon Rd Name of chief executive officer (CEO) of organization First name Last name (Rev.) Thomas Fitz2erald Name of teasurer of organization First name V;rOJ;n~O\ Last name ~ Mo#-t; For Board .Use Only Fee Paid Page 1 of 2 Check No, 10/98 Initials Received-1 '_ Type of Nonprofit Organization Check the box that best describes your organization: o Fratemal IXI ReUgious o Veteran o Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: o IRS letter indicating income tax exempt status o Certificate of Good Standing from the Minnesota Secretary of State's Office o A charter showing you are an affiliate of a parent nonprofit organization o Proof previously submitted and on file with the Gambling Control Board Au.9 . 2f), zo{) to Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles. list the site where the drawing will take place) Church of St. Genevieve Address (do not use PO box) 7087 Goiffon'Rd. City Centerville Date(s) of activity (for raffles. indicate the date of the drawing) StatelZip Code MN 55038 County Anoka Check the box or boxes that indicate the type of gambling activity your organization will be conducting: lXJ *8lngo [iJ Raffles ~ *Paddlewheels 5l*Pull-Tabs lXJ *Tipboards *Equipment for these activities must be obtained.from a licensed distributor. This form will be made available in alternative fonnat ~.e.large print BraiDe) 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 aGtivities in Minnesota YOI. have the right to refuse to supply the information requested; however. if you refuse to supply this infonnation. 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. I 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 rUt 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 organizationls 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 Minf'Agota Legislative Auditor, national and international gambling .regulatory agencies; - anyone pursuant to court order; other individuals and agendes 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 infonnation after this Notice was given: and anyone with your consent. - I 39