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Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit Fee $50 <br />An exempt permit may be issued to nonprofit organizations <br />conducting lawful gambling activity on five or fewer days, and <br />awarding less than $50,000 in prizes during a calendar year. <br />Organization Information : r �_ ;�� <br />R�_e 1 uf2 11/Q4 <br />For Board Use Only <br />Fee Paid <br />Check No. <br />{'� y��i�BL ;' •L�= Il�,l'1!' I't�a�Ut�� �iL= -30 r,r :�Y�:�i�d: .. ....�i�lu•i. �i �3ii�r <br />ar� '� ��-��-C��•�� �� �-:�} ���� �-����� �' � ��� � � <br />SS� r.r.t •�fIY � Llsl� 8rl�l zlp �ade ��oUnl� <br />� �� � ��'�� � � � ����i`�•� � ��f ��i� ,����}'��•�� <br />—. .� _ . � - <br />�+a�� Gf �i�f Cx+�GUlivr. C�Ifx:er tL't{�� � ' <br />=irsl nam� L�SF fl � D:�yrtu�ie p17Ui1� i7�i1L7�f <br />��-�`�� l��-;�-���� � � �} �{�s� ��}�� � <br />Type of nonprofit organization (check one) <br />❑ Fraternal � Religious <br />❑ Veteran �, Other nonprofit organization <br />Type of proof of nonprofit - attach a copy (see instructions) <br />❑ Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office <br />� Internal Revenue Service <br />� Affiliate of parent nonprofit organization (charter) <br />Gambling Premises Information <br />p��m� ^��rv.�i�� x�r�rr. �3�r.lr:i� n4�,rd� �n�ill be conducted (for raffles, list the site where the drawrng'�r�•� take place) <br />�i � �� C�.������� �k � ;� � � L��y � ��—� <br />Address (do not use PO box) I rr� � yy I Zip code C�,r•i'.; <br />. � �r +Y.�f � �• yf:} � f ,/ � � s <br />y � 2J•J •� �f- f_.�,'Y ��{•L b�i� 2 1 ��l r����� � � � '� � � � �.v • ti /° <br />' ' � �• ��' �4 �v`•�_:��% L� <br />Date(s� of activity (for raffles, indicate the date of the drawing) � � <br />,� <br />, <br />� �� �� ' - - • �.�.:�� � <br />��-� ff-� <br />Check�he box or boxes that indicate the type of gambling activity your organization will be conducting <br />� - 3 ••��u � 14�'���_ � ' ��� •�,:,,�1-��a�E�; ❑ "F'� T�i,s � ' � uL��•,.i � I� <br />'Gambling equipmentfor pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball <br />selection-device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed <br />distributor, go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. <br />This formwill be made available in alternative <br />format (i.e. large print, Braille) upon request. <br />The information requested on this form (and <br />any attachments) will qe used bythe Gambling <br />Control Board (Board) to determine your <br />qualificationsto be involved in lawfulgambling <br />activities in Minnesota. You have the right to <br />refuse to supply the information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able to <br />determine your qualifications and, as a <br />consequence, may refuse to issue you a <br />permit. If you supply the information <br />requested, the Board will be able to process <br />your application. <br />Your name and and your organization's name <br />and addresswill be public informationwhen <br />receivedbytheBoard. Alltheotherinformation <br />that you provide will be private data about'rr•-� <br />untiltheBoardissuesyourpermit. Whenthe <br />Board issues your perm it, all of the information <br />that you have provided to the Board in the <br />processof••�Y�;i-r.�:r� �rv•:-x���-�I•nilbecome <br />public. If the Board does not issue }n'�i a <br />permit, all the information you have provided <br />in the process of applyingfor a permit remains <br />private, with the exception of'•'a'�� name and <br />your organization'sname and addresswhich <br />will remainpublic. <br />Private data about you are available only to <br />the following: Board members, staff of the <br />Board whose work assignment requiresthat <br />they have access to the information; the <br />Minnesota Department of Public Safety; the <br />Minnesota Attorney General; the Minnesota <br />Commissioners ofAdministration, Finance, <br />and Revenue; the Minnesota Legislative <br />Auditor, national and international gambling <br />regulatory agencies; anyone pursuantto court <br />order; other individuals and agenciesthat are <br />specifically authorized by state or federal law <br />to have access to the information; individuals <br />and agencies for which law or legal order <br />authorizesa new use or sharing of information <br />afterthis Notice was given; and anyone with <br />yourconsent. <br />