2003_1020_packet - Laserfiche WebLink

Home

Minnesota Lawful Gambling L 240R Application to Conduct Excluded Rafe (No fee) 06103 If your organization has been licensed or exempted in the current calendar year, you are not eligible to apply for excluded raffle. Organization lnformation Previous authorization number, if any Orga ' ation Name as it appears ( ppears on docu entat an filed with Minnesota Secretary of State or Internal Revenue Service) Street city emu} ¢ - � •�� S�,C+�% Zip cage- � ounty Type of nonprofit organization (check one) Fraternal Veteran Religious XOther nonprofit organization Type of proof of nonprofit - attach a copy (see instructions): Certificate of Good Standing - Minnesota Secretary of State's Office �Internai Revenue Service `Affiliate of parent nonprofit organization (charter) Excluded Raffle Activity Information Date of raffle drawing _ - — /__Z-1i/_ Total market value of raffle prizes p jJ (The value of all raffle prizes in la calendar year may not e_x" a �u1500. ) Name of the person in charge of raffle @� Q4a V s�. Phonei-S l'�W'04i1t0 ..d_ Premises Where Excluded Raffle Will Be Conducted Name o remiises M Street Address (do no e PO box) G Zh = Oi. rp I City or t nship Q�unt�y ' �� NO Chief Executive Officer's Signature The information provided in this applicat' is complete and a ui to to the best of my knowledge. Chief executive officer'ssignat IS Phone number Name (please print) 0 Date(D This form will be made available in aftemative format (i.e. large print, Braille) an authorization, all the information you have provided in the process of upon request. The information requested on this form (and any applying for an authorization remains private, with the exception ofyour attachments) will be used by the Gambling Control Board (Board) to name and and your organization's name and address which will remain determine your qualifications to be involved in lawful gambling activities in public. Minnesota. You have the right to refuse to 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 an authorization. if you supply the information requested, the Board will be able to process your application. Your name 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 or authorization. When the Board issues your authorization, all of the information that you have provided to the Board in the process of applying for your authorization will become public. If the Board does not issue you Mail Application and Attachment(s) Private data about you are available only to the following: Board members, staff of the Board whose work 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 pursuant to court order, other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information afterthis Notice was given; and anyone with yourconsent. Send the completed application and a copy of your proof of nonprofit status at least 30 days prior to the activity date to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113