2005-05-25 CC Agenda - Laserfiche WebLink

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For Board Use Only Minnesota Lawful Gambling Fee Paid Page 1 of 2 Check No Application for Exempt Permit - LG220 10/98 Initials Received / / Organization Information Organization name Previous lawful gambling exemption number Church of S t. Genevieve )(- 19{)(),y Street City State/Zip Code County 7087 Goiffon Rd Centerville MN 55038 Anoka Name of chief executive officer (CEO) of organization Daytime phone number of First name Last name CEO: (Rev. ) Thomas Fitzgerald 651-429-7937 Name of teasurer of organization Daytime phone number of First name Last name Virginia LaMotte 651-429-8316 . Type of Nonprofit Organization Check the box that best describes your organization: o Fratemal ~ Religious 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 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) City StatelZip Code County 7087 Goiffon Rd. Centervi1le MN 55038 Anoka Date(s) of activity (for raffles, indicate the date of the drawing) August 21, 2005 Check the box or boxes that indicate the type of gambling activity your organization will be conducting: rg1*Singo 5Zl'Raffles &a'*Paddlewheels IKf*Pull-Tabs CS?*Tipboards *Equipment for these activities must be obtained from a licensed distributor. This fonn wiil be made available in alternative fonnat (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) wiil be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawiul gambling activities in Minnesota. You have the right to refuse 10 supply the information 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 wiil 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 permn, all of the infonmation 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 penmit, 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 oniy to the following: Board members, staff of the Board whose wor!< 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 Legislative Auditor, national and international gambling regulatory agencies; anyone pursuantto court order, other individuals and agencies that are specifically authorized by state or federai law to have access to the infonmation: individuals and agencies for which law or legal order authorizes a new use or sharing of information aflerthis Notice was given: and anyone with your consent.