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Jul 25 02 08; 10a ERRMERS INS 61 22432779 p. 2 Pagel oft 3101 Minnesota Lawful Gambling ar Board o u only LG220 w Application for Exempt Permit Fee $2 Fee Pai Organization informatior% Check No. � � Organization name Previous lawful gambling exemption number—,9�a -e 4,oleo 00�6:��44 4 Z:�5 ,,J-I'C'Ec 4W A17,Street City State/Zip Cede County Name of chief executive officer(CEO) First name fast name Daytlrqe phone number of CEO 3 3 6 — 4,,ele 3 14411 its Ur t1U-dZUret DayUrne phone number of First name Last name treasurer: Type of Nonprofit Organization Check the box that best describes your organization: Fraternal E] Religious [� Veteran ''Other nonprofit organization 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 tile with the Gambling Control Board Gambling Premises Information Name of premises w eregambing activity will e conducted(for raffles,ISt the site where the drawing willhke place) Address (do not use PO box) City State/Zip Code County Date(s) of acuity (for raffles, indicate the date of the drawing) Check the box or boxes that hdicate the type of gambling activity your organization wiu be conducting: C]*Bingo Z Raffles(cash prizes may not exceed$12,000) LJ Taddlewheels ,ED `Pull-Tabs Mpboards `Equipment for these activities must be obtained from a licensed distributor. This form will be made available in Your name and and your organization's the following: Board members,staff of the alternative format (i.e, large print, Braiile) name and addressvwl be public information Board whose work assignment requires upon request. The information requested when received by the Board. Aii the other that they have access to the information; on this form (and any attachments) wil be information that you provide will be private the Minnesota Department of Pu blic safety, used by the Gambling Control Board data about you until the Board issues your the Minnesota Attorney General;the (Board) to determine your qualifications to Permit. When the Board issues your Minnesota Commissioners of be invoived in lawful gambling activities in permit, aii of the information that you have Administration, Finance, and Revenue; the Minnesota. You have the right to refuse to provided to the Board in the process of Minnesota Legislative Auditor, national and supplythe information requested: however, applying for your permit will become public. international gambling regulatory agencies;, if you refuse to supply this information, the If the Board does not &sue you a permit, anyone pursuant to court order; other Board may not be able to determine your all the information you have provided in he individuals and agencies that are qualifications and, as a consequence, may process of apply q for a permit remains specifically authorized by state or federal refuse to issue you a permit, if you Stipp private, with the exception of your name law to have access to the information; the information requested, the Board w I and yourorganlzatbn's name and address individuals and agencies for which law or be able to process your application. which will remain public. e9W order au horizes a new use or sharing Private data about you are available oniyto of information after this Notice was given; and anyone with your consent.