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<br />Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit <br /> <br />Fee $50 <br /> <br />Page 1 of2 <br /> <br />11/04 <br /> <br /> An exempt permit may be issued to nonprofit organizations For Board Use Only <br /> conducting lawful gambling activity on five or fewer days, and Fee Paid <br /> awarding less than $50,000 in prizes during a calendar year. Check No. <br />Organization Information <br />Organization legal name Previous license or exemption number, if any <br />~~\IlL-l-\C 1-1 bt-..\ ? Lt.-u\~ <br />Street City State and zip code County <br />/('7,? ~A"'" Di2...,,,,"" ~~\lu.....,-~ V"'.,J 7'7c>3S rA~t>.~ <br />Name of chief executive officer (CEO) <br />First name Last name Daytime phone number <br />-r ~-' ~(Z~e" k:J7\ ,..~~- ltb30 <br />Type of nonprofit organization (check one) <br />D Fraternal D Religious <br />D Veteran YOther nonprofit organization <br />Type of proof of nonprofit - attach a copy (see Instructions) <br />~NonprOfit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office <br />D Internal Revenue Service <br />;a-Affiliate of parent nonprofit organization (charter) <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 />~....rr~I~ t..-A It- €" <br />Address (do not use PO box) City Zip code County <br />\-1~ u~;2-lJ~ -7C?O~ ~DlIL.'A <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />FE-~. " \ 'fi+, Z--t:rp ~ AL-"\\'aJ2.t..,l ~ ~. R-j3. r~-"" ~J "2-00 b <br />Check the box or boxes that indicate the type of gambling activity your organization will be conducting: <br />D *Bingo %Raffles D *Paddlewheels D *Pull-Tabs D *Tipboards <br />*Gambllng equIpment for pull-tabs, t1pboards, paddlewheels, and bIngo (bIngo paper, hard cards, and bIngo ball <br />selection devIce) must be obtaIned from a dIstributor licensed by the Gambling Control Board. To find a licensed <br />dIstributor, go to www.gcb.state.mn.us and click on LIst of LIcensed DIstributors. Or call 661-6394000. <br /> <br />This form will be made available in altemative <br />format (i.e. large print, Braille) upon request <br />The information requested on this form (and <br />any attachments) wiD be used by the Gambling <br />Control Board (Board) to determine your <br />qualifications to be Involved in lawful gambling <br />activities In Minnesota. You have the right to <br />refuse to supply the Information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able .to <br />determine your qualifications and, as a <br />consequence, may refuse to Issue you a <br />permit. If you supply the Information <br />requested, the Board will be able to process <br />your application. <br /> <br />Your name and and your organization's name <br />and address will be public Information when <br />received by the Board. All the other information <br />that you provide will be private data about you <br />until the Board Issues your permit When the <br />Board issues your permit, all of the Information <br />that you have provided to the Board In the <br />process of applying foryourpermltwID become <br />public. If the Board does not Issue you a <br />permit, all the Information you have provided <br />in the process of applying for a permit remains <br />private, with the exception of your name and <br />your organization's name and address which <br />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 that <br />they have access to the Information; the <br />Minnesota Department of Public Safety; the <br />Minnesota Attomey General; tha Minnesota <br />Commissioners of Administration, Rnance, <br />and Revenue; the Minnesota Legislative <br />Auditor, national and Intematlonal gambling <br />regulatory agencies; anyone pursuantto court <br />order, other IndMduals and agencies that are <br />specifically authorized by state or federal law <br />to have access to tha Information; IndMduals <br />and agencies for which law or legal order <br />authorizes a new use or sharing of Information <br />after this Notice was given; and anyone with <br />your consent <br /> <br />15' <br />