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Minnespta Lawful Gamblr"r�g � (�77(i �nnli�a#inn fnr F�rrsmn� Pcsrmi# Page 1 of2 99/04 Fr�r.� ±��(1 -----°-- - -��--_�,_._.. .._. _.,._...�_ . _...... . -- .�—_ ForBnardEJseOnly An exempt permit rt�ay be issued to nanprofEt organ4zations conductir�g lawFul gambling activity on five nr fewer days, and Fee Paid awarding less than $5Q,000 in prizes during a caler€dar year. Gheck Na. Organszatint� Infarrnation Or anization fegai name Previous I'scense or exemption nurttber, if arzy � �� ;f� ��-Gcao� �i ��- x�-��' Street City � SYate and zip code Caunty i �d o.S�? ( 1� �. �--e Name of chief executi � offie�r (C�O) Firsf narr�e � Last name baytime phane number ` �, � � c� +-� S 0 �7 -� �� Typ� af nonpro�i prganizafior� (check one) ❑ �rafernal ❑ Fteligious ❑ Ve#eran �fher nonprofit arganization �'ype of proof of nonprofit - attach a copy (see instruciions} ❑ Nonpra#it Articies af f ncorporatian ar Cerfificate of �oad Standing - Minnesota Seere#ary of 5tate's Office ❑ Infernal Revenue Servioe �jfiliate nf parent nonprofit nrganizatinn �charter) Garr�bting Premises Informa�ion Nar�':e nf premises where gaml�ling ctivity will be canducted (for raffles list the site +nrhere th� dra+nring wlf take place) ��i�i r✓�" j'�'i �'"�'.- �� '��"�� G✓�'P� d � � Address (da not use p0 box) Ciiy Zip code County 0� � 6 �� l �� '-��r'�"� Date(s) of activity jfor reffl s, indicate fhe date of the drawing) y � � �� Check the box or boxes #hat indicate the type of gambling acEi�ity your organiza#ior� will be conducting: � *Bingo �RafFfes ❑ `Paddiewheels ❑ 'Pufl-T�bs ❑ 'Tipboards / � `Gambling eq�ipment for pulf taE�s, Eipboards, paddlewheels, and bingo (bingo paper, hard cards, and tsingo baN selection devies) must be obtained ixo�n a distributor iicens�d by the Gambling Contro! Soard. 'To find a licensed distrihutor, go Eo tvww.gcb.stafe.mn.us and click on List oi �.icensetl Distribuiors. Ctr cal[ 651-838-4D(iU. ihis form will be made available in alternative Yaur name and and yourorganization's name the fotlowis�g; Board members, siaSE of the farmat (i.e, large print, Srai11�) upon request. The infarmation requested on this Form (and any attach�nants) wil9 be used by the Gambfing Controt E3aard (8aard) ia dstermine your quafifeatians to be involved in iawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; howeve€, if you refuse to supply this informai€on, fhe Baard may nat be able to @efermine yoUr qualifications and, as a cnnsequencs, may refuse to issue you a permii. If you suppfy the information requested, the 8oard wiii be a61e !o proces& your ap�licatian. anc� ac�dress w33� ae put�ue intormatio� wnen rsceivedbyUte6oard, Atltheotherinfarmation that you pravide wiA Y�e privake data about you �aniii if�e $oard iss�es your permit. Whert the Baard issues you€ permit, all of the informaEion that you have pravided ta the Board '€rt the process af applyi�g foryour permit wilE become public, if the Baard does not issue you a permif, all the infprrnation you hava provided in ihe process nf appfying for a permit remains private, with the excepiian of ypur name and yourorganization's name and address which will rerrsain pu6lic. Privaie data abaut you are available onfy to Board whos� work assignrt�ent requires that they have access to tEte informatian; the Minnesnta �epartrr€enf of Public Safety; the Minnesota Attorney Generaf; the tvlinnesnta Commissioners ofAdministration, Finance, and Revenue; fhe Minnesota L.egislative Auditar, nattona4 anci'snterr,aEiana! gambling regulaEory agencies; anyone pursuant to caurf order; nth�r individ�als and agencies tttat are spacifically author€zed by slate pr federal law ta have acce5s to the informat€on; indiv€duals and agencies for which law or 6aga1 nrder autf�orizes a new t�se or sharing of infarmation after khis �latice v,ras given; and anyone with your consent.