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mneso a a u am mg I For Board Use Only LG220 Application for Exempt Permit Fee $50 Fee Paid Organization Information Check No. Organization name Previous lawful gambling exemption number ~~;2.v,,-~ L-lD.....l LL-Wi). y..~ 47:2-C7 Street City StatelZip Code County 76'7 ~\P.-..l ~"" ?e~.,-wC M,..l 970 3-$ A.....b~ Name of chief executive officer (CEO) Daytime phone number of CEO First name Last name ~o~ V-VA'MMlE br;l-b'?~~ 2-o,=>0 Name of treasurer Daytime phone number of First name Last name treasurer:'-'7"1_4"2-'7_2-14... -roM. WIl-.....A~i2... Type of Nonprofit Organization Check the box that best describes your organization: D Fraternal ~eligiOUS D Veteran Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: D IRS letter indicating income tax exempt status i:certificate of Good Standing from the Minnesota Secretary of State's Office charter showing you are an affiliate of a parent nonprofit organization . 'J:2r Proof previously submitted and on file with the Gambling Control Board Gamblina Premises Information Name of premises where gambling aclivity will be conducted (for raffles, list the site where the drawing will take place) L-At-I:2-l ~ 1.-1'< """''!Tit" ~;2.lL Address (do not use PO box) City SlatelZip Code County C,.p.~eO-\I,~ '/I^...l b971> L-AMO<n< D~IIC '7"7p3$. A..-Jb~ Date(s) of aclivily (for raffles, indicate the date of the drawing) f\\.>~ ""', 7 ... 4!-, :?-at:>",\- ~: box or boxes that indicate the type of gambling activity your organization will be conducling: 'Bingo D Raffles (cash prizes may not exceed $12,000) D 'Paddlewheels D 'Pull-Tabs D'Tipboards 'Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. M' tLwfI/G br This form will be made available in alternative fonnat (I.e. large print, Braille) upon requesl The infonnation requested on this form (and any allachments}win be used by the Gambling Control Board (Board) to detennine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the infonnation requested; however, if you refuse to 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 infonnation that you provide will be private data about you until the Board issues your permit VVhen the Board issues your pennil all of the infonnation that you have provided to the Board in the process of applying foryourpennftwill become public. If the Board does not issue you a pennil all the informalicn 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 Page 1 of 2 (web) 12/03 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 MinnesotaAttomey 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 individuaJs 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 ofinforrnation after this Notice was given; and anyone with your consent