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LG200A - Organization License Application Page 3 of 3 5101 Organization Income and Activities (attac1h additional . � Io��tl sheets �f n��e�s��Y� An org on may not exist solely to conduct lawfLd gat blin�. List other a�vi�es through - r es funds gh v4ch your or9aWzabon �on r , u • lions from public and other charitable • _ - orn�a ions In comparison th funds you rise a profit organization, what is the percent of fund a you will raise through i awf gambling? ng� _ � g Acknowledgment I declare that: l have read this applicaon and ail Information submitted to the Board. AN information is true, accurate, and complete. All other required information has been fully disclosed. a I am the chief executive officer of the organization. assume full responsibility for the fair and lawful opera- tion of all activities to be conducted. will familiarize myself Wth the laws of Minnesota governing lawful gambling and rules of the Board, and agree, If licensed, to abide by those laws and rules, inducing amendments to them. Signature of Chief Executive officer Ayachments and Required Infl6rmation LG200A organization License Application LC o0B Organization Officers Affidavit a CEO and treasurer must each complete Proof of non p roft status Organization bylaws Membership listaigned by CEO and notarized. Include date of membership for each person. LC o 1 Internal Controls Attach a flow chart shoWng the structure of your o rganizeti on and a separate wri #ten epl an atio n of administrative duties* Mall To: Gambling Control Board Suite Soo South 1 711 W. County Road B Roseville, MN 55113 The information requested on this form (and arty attachments) will be used by the Gambling Control Board (Board) to determine your quali- fications to be involved in lawful gambling ao` tivities in Unnesota, and to assist the Board in conduce a background investigation of you: You have the right to refuse to suppler 1he in- forrnadon requested; however, it you rerun to amply fie information, the Board may net be able to determir+e your %mlifiications and, as a cormquenoe, may refuse to issue you a rcense. If you OuPPlythe information reques�qd, the Board Will be able lo process your apphcaT lion. This form may require the disdosure of your Social Security number. If so, your Soci ai Security numberwill be used to determine your Date, L 205 -Coro ensa p ton Schedule Use to report all wages paid to employees Involved in the conduct of lawful gambling- * If no wages paid, return the L 205 signed hy* the CEO stating "No compensation paid. L 209 Registration of Paid Gambling Employee (if any). Qu onsy Call the Licensing Seclon of the Gambling Control Board at 61- 6394000. if you use a TTY, you can call the Board by using the Minnesota Relay Service at 1- 800- 627 -3529 and ask to place a call to 661-W94000. This form will be made available in alternative fcmwt (i,e. large print Braille) Upon request, compliance with the tax laws of Minnesota. Auftdzalon for requiring your 6001W seurrity number is found qt4 MD. . Your name and address will be PUMic infor- mation when received by the Board. All the other information g- at you provide will be pri- vate data about you until the Board its Your- license. When the Board issues your tke nom, an of the i rfo rrnation that you have provided to the Board in the process of apply. ing for your Iloonse win becorne pubNc except for your Social Security number, which remains private. If the Board does not i you a ikon . all the inf orrnation you have pm- vided in the process of applying for a licenso remains private, wrth the exception of your name and address which will remain public. Private data about you are available only to ft UIOWing: Board rnembers, staff of the Board assi nme t requires that the have access to the information; the Minnesota Departent of Public Saflaty. the Minnesota Attorney Canal' the Minnesota Cornrriissivri- era of Adntini*aVon. Finance, and Revenue; the M1 11080ta Legislative AudhDr, national and international gambling regulatory agerides; any011e pursuant to court order, 9ther incfivldu- als and agencies that are specifically autho- Hzed by state or federal law to have access to the information; inclividuals and agencies for which lave or legal order authorizes a new use Or sharing of information after this notice was given; and anyone with your consent