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For Board Use Only Fee Paid Minnesota Lawful Gambling page 1 o f check No Application for Exempt Permit LG220 1 0/98 Initiais Received Organization Information Organization name Previous lawful gambling exemption number Street City State/Zip Code County IYame of chief executive officer (CEO) of organization Daytime phone number of _f First name Last name CEO: PJame of teasurer of organization Daytime phone number of First name Last name treasurer: ( } Type of Nonprofit Organization Check the box that best describes your organization: Fraternal ❑ Religious Veteran ❑ Othernonprofitorganiration Check the box that indicates the type of proof your organization attached to this application: ❑ IRS letter indicating income tax exempt status Certificate of Good Standing from the Minnesota Secretary of State's Office A charter showing you are an affiliate of a parent nonprofit organization 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") Address (do not use PO box) City State,20 Code county 114 L (.7 a#e(s) of activity (for raffles, indicate the date of the drawing) NA �� fir. .C,o heck the box or boxes that indicate the type of gambling activity your organization wit#be conducting: [D *Bingo M Raffles [ `Paddlewheels [3*Pull-Tabs `Tipboards Equipment for these activities must be obtained from a licensed distributor. MM This form will be made available in alternative Your name and and you rorganizati 's name Private date about you are available only to the format (i.e.large print, Braille)upon request, The and address will be public information when following:Board members,staff of the Board information requested on this form (and any received by the Board, Alf the other information whose work assignment requires that they have attachments)will be used by the Gambling. that you pry We will be_pdvate data about you access to the information; the Minnesota Control Board (Board) to determine your until the Board issues your permit. when the Department of Public Safety; the Minnesota quaiicatiors to be mtiovd in lawful gambling Board issues Yo ur permit, of the inibrmaon Ao � General: the Minnesota Commissioners activifi" in Minnesota. You #gave the right to that you have provided to the Board in the of Administration. Finance, and Revenue; the refuse to supply the information requested: process of appfying for your permit vW1 bewme Minnesota Legislative Auditor, national and however, if you refuse to supply this information, public. If the Board doss not issue you a permit, international gambling regulatory agencies; the Board may not be able to determine your all the information you have provided in the anyone pursuant to court order; other indiwduais q u a I i i n s and,as a consequence,may refuse PmeeSs of applying for a permit remains private, and agencies that are specificaii authorized by to issue you a permit., If you supply the with the exception of your name and your state or federal law to have access to the information requested, a Board w6l be able to organization's name and address which will information; individuals and agencies for which the g process your application. or tion, remain public. law Iega!order authorizes anew use or sharing of infomnation after this Notice was given; and anyone wiM your consent.