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Minnesota Lawful Gambling Application to Conduct Excluded Raffle - LG240R 3/99 If your organization has been licensed or exempted in the current calendar year, you are not eligbte to apply for excluded raffle. Organization Information FOR BOARD USE ONLY Organization Name Proof Cerat IL' L, s I I 1 sn c Street o fl N L.1 NA Li 1167 (KJtC 54i,a I • City County State/Zip Other Activity M A! Cso3sr' Type of nonprofit organization (check one): CEI Fraternal ❑ Veteran Religious ❑ Other nonprofit organization Type of proof of nonprofit - attach a copy (see instructions): ❑ Certificate of Good Standing - Minnesota Secretary of State's Office Internal Revenue Service Affiliate of Parent nonprofit organization (charter) Excluded Raffle Activity Information Date of raffle drawing - 6 / 2 ' / CO Total market value of raffle prizes $ 752 c r /e , (The value of all raffle prizes in a year may not exceed $750.) Name of the person in charge of raffle Pc [ S I `z- t Phone ( ) Premises Where Excluded Raffle Will Be Conducted Name of Premises i�t /lf� hl� Pc„ric Street Address (do not use PO box) 6' 1- a r e ) - 'E City,- / I� ' // Co FANn1 Township Chief Executive Officer's Signature The information provided in this application is comp to and curate to the best of my knowledge. Chief Executive Officer's signature / Name (please print) ..l1w av-c -C Date C / Q3 / Cc Mail Application and Attachment(s) Acknowledgment of Gambling Control Board Send the completed application and a copy of your proof of Your request to conduct excluded raffle has been received nonprofit status at least 30 days prior to the activity date to: and is acknowledged by the Gambling Control Board. Gambling Control Board Acknowledged by: Suite 300 South 1711 West County Road B Date, // Roseville, MN 55113 Licensing Specialist This form will be made available in atematioe format (i.e. large print, of applying for your authorization will become public. tf the Board Braille) upon request. The information requested on this form (and does not issue you an authorization, all the information you haw any attachments) we be used by the Gambling Control Board (Board) provided in the process of applying for an authorization remains private, to determine your qualifications to be involved in lawful gambling with the exception of your name and and your organization's name activities in Minnesota. You have the right to refuse to supply the and address which will remain public. nfornaton requested; however, if you refuse to supply the intonation, Pie data about you are available only to the following: Board the Board may not be able to determine your quatfications and, as a consequence, may refuse to issue you en authorization. If you supply the ha staff s the Board whose work in assignment requires t the information requested. the Board will be able to process your that they have access to the information; A Minnesota Department to applcatan. Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Your name and your organization's name and address will be public Minnesota Legislatne Auditor, national and international gambling information when received by the Board. Al the other information that regulatory agencies; anyone pursuant to court order, other Individuals you provide will be private data about you until the Board issues your and agencies that are specifically authorized by state or federal law pent or authorization. When the Board issues your authorization, all to haw access to the information; individuals and agencies for which of the formation that you have provided to the Board in the process law or legal order authorizes a new use or sharing of intonation after the Notice was given; and anyone with your consent.