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<br />t' <br /> <br />Minnesota Lawful Gambling <br />LG220 - Application for Exempt Permit <br /> <br />Organization Information <br />Organization name <br />5-~ (/C?lI/cV / e(,1 C <br />Street <br />'""7&87 QUA -c>N to <br />Name of chief executive officer (CEO) <br />First name <br />h . ~iV/A5 <br />Name of treasurer <br />First name <br /> <br />Fee - $25 <br /> <br />Page 1 of 2 8/00 <br /> <br />For Board Use Only <br /> <br />Fee Paid <br /> <br />Check No. <br /> <br />C). ..' /) P~evious lawful gambling exemption number <br />';f-1Ifdt--1 <:. \..'Ift<,eetl 1I/J1/A/AJ X - 9~a()(j'-C)d-co. _ <br />C~~ State/Zip Code County <br />L;'~FTe7f. (/ f L ~ c /!Iv 5P 38 ,I1Ak1{-(./f <br /> <br />Last name <br />h-rZGG#+LD <br /> <br />$(Me r~ ,A8uj,f E <br />Type of Nonprofit Organization <br /> <br />Last name <br /> <br />Daytime phone number of CEO <br /> <br />&5'"1- q~1 - 7~:37 <br />Daytime phone number of <br />treasurer: <br /> <br />Check the box that best describes your organization: <br />o Fraternal [8l Religious <br />D Veteran D Other nonprofit organization <br />Check the box that indicates the type of proof your organization attached to this application: <br />o IRS letter indicating income tax exempt status <br />o Certificate of Good Standing from the Minnesota Secretary of State's Office <br />o A charter showing you are an affiliate of a parent nonprofit organization <br />~ Proof previously submitted and on file with the Gambling Control Board <br /> <br />Gambling Premises Information <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br /> <br />5:1'ME A-s ,lf6ol/ E <br /> <br />Address (do not use PO box) City State/Zip Code County <br /> <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br />B//q /0/ <br />Check the box or boxes that indicate the type of gambling activity your organization will be conducting: <br />D?I.Bingo [XJ Raffles rn *Paddlewheels ~.PulI-Tabs IXI.Tipboards <br />.Equipment for these activities must be obtained from a licensed distributor. <br /> <br />This form will be made available in <br />alternative format (i.e. large print, Braille) <br />upon request The information requested <br />on this form (and any attachments) will be <br />used by the Gambling Control Board <br />(Board) to determine your qualifications to <br />be involved in lawful gambling activities in <br />Minnesota. You have the right to refuse to <br />supply the information requested; however, <br />if you refuse to supply this information, the <br />Board may not be able to determine your <br />qualifications and, as a consequence, may <br />. refuse to issue you a permit If you supply <br />the information requested, the Board will <br />be able to process your application. <br /> <br />Your name and and your organization's <br />name and address will be public information <br />when received by the Board. All the other <br />information that you provide will be private <br />data about you until the Board issues your <br />permit When the Board issues your <br />permit, all of the information that you have <br />provided to the Board in the process of <br />applying for your permit will become public. <br />If the Board does not issue you a permit, <br />all the information you have provided in the <br />process of applying for a permit remains <br />private, with the exception of your name <br />and your organization's name and address <br />which will remain public. <br />Private data about you are available only to <br /> <br />the following: Board members, staff of the <br />Board whose work assignment requires <br />that they have access to the information; <br />the Minnesota Department of Public Safety; <br />the Minnesota Attorney General; the <br />Minnesota Commissioners of <br />Administration, Finance, and Revenue; the <br />Minnesota Legislative Auditor, national and <br />international gambling regulatory agencies; <br />anyone pursuant to court order; other <br />individuals and agencies that are <br />specifically authorized by state or federal <br />law to have access to the information; <br />individuals and agencies for which law or <br />legal order authorizes a new use or sharing <br />of information after this Notice was given; <br />and anyone with your consent <br />