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Minnesota Lawful Gambling
<br />LG22U Application for Exempt Permif Fee $50
<br />An exemgt permit may be issued to a nonorofit organization
<br />�clu^irri� �,nrrf�i! gambling activity on five or fewerdays, and
<br />awarding less than $50,OOOin prizes durings a calendar year.
<br />Organization Information
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<br />Name of chief �XeCUflve officer (CEO)
<br />Fir�E Flam�' . �
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<br />Type of NonprofitOrganization
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<br />Page 1 of 2 2106
<br />For Board Use On[y
<br />Fee Paid
<br />Check No.
<br />Previous lawful gambling exemption number,
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<br />State/Zip Code County
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<br />E{�� _ Daytime phone number
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<br />Type of nonprofit organization (check one)
<br />n Fraternal Religious
<br />� Veteran � Other nonprofit organization
<br />/
<br />Type of proof of nonprofit status- attach a copy (see instructions)
<br />❑ Nonprofit Articles of incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office
<br />I� Internal Revenue Servic�
<br />� Affiliate qf parent nonprofit organization (charter)
<br />� Proof previously submitted and on file with the Gambling Control Board
<br />Gambling Premises Information
<br />��rir.r tiF � r�•�,is�s ���F�•a �a�• - � � a '�rril�• tiy'ii =� ccnd��had,.'�cr ra�lts, li�;� ��,: �ii� ��.h�re �e •Y;as�•.ng •�+iU ;a�e GIa:Yej
<br />, $ �
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<br />�ndrass �do r� �s R�r �aa� . rtt� � �i� � f �.�ounty
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<br />raf�.'�j ofactivit�(for raffles, indicate the date ofthe drawing)
<br />�{ L .-} � �� i�
<br />rhectcthe box arboxes that indicate the type ofgambling activity your organization wiil be conductir�g:
<br />� 'Bingo � R�ffies �I �Paddlewi�e�)s � *P�li-Tabs ❑ "Tipboards
<br />'Gambling eq ipmentfor pull-tabs, tipboards, paddiewheeis, and bingo(bingo paper, hard cards, and bingo ball
<br />selection device) mustbe obtainedfrom a distributorlicensed bythe Gambling Control Board. Tofinda licensed
<br />distributor, gotowwuv.gcb.state.mn.usandclickonListofLicensedDistributors. Or��651-639-4000.
<br />T�is iorm ��.=1 i� m�r,ic ati�a�l��in if�T�1��
<br />',rrn�t 1i t.:arx�e �rrt, E�aiaer 4�on rey^�est.
<br />i he information reauested on this form (and
<br />arr a!':x'•rrr: ds: w�l �= �se� FY ='i_ �aris� rk
<br />t,:l'��ri}� �titil': �eJY'L�,� :U L'=�r�"•�;.� }';:'.I�
<br />���I j�v�-..;r�.l;•r�r;�nvv�4•FO�P 4,�'.i�S�Thi�1
<br />eci�itzs �n F,�nesata. 'fav h�ae �� ��hr ipn
<br />�fu�e la ��p� hv �• `_� rul'firy :a�aested;
<br />however, if ��-i refuse to supply this
<br />I!I�'."�f��UCfI. ih� ��}�''L!�75� �OI OE d}�}i�
<br />ii�lerm'ia ya�� Qu9e--Fl�atiMns �ng� as a
<br />consequence, may refuse to issue you a
<br />�Sr��m�: 't ��� ;Ir��� ��e =.if�r•i•n9�-�i
<br />��qwes�e�f. *�� �csaad �x� ta aa'.e ro pmcess
<br />: c,��application.
<br />''4a: I��a�A � �{'a Y,;; �zat�4�Y'& �°a�
<br />�+x: �d�rags �titi� :�e �wl�i,e :r!l�::: �1 �ar; ,ri!�r.
<br />received bY �he Board. Ai2 the other information
<br />Ir�i'� �4 Crr.�.�nr :�,� I?�� Yr �rB;K {13� ,i�,:t�:'rUu
<br />�,�li IF:; Nt,ai � is�.ies y��ar �r�m��� ', rl•�n I`.�
<br />@t�,•vi��aQ�'rC�.:t:E•i�� �I af'�r. �I::i:nr-�o-•i
<br />113at X4W �'�� P�4i�t� EC t�e E'�^� �� �1�e
<br />�f�tc'E9 of a�►fing Sor}�iurGGrT�3•+� c�e�a�^�
<br />If the Board does not issue a
<br />'�S'• I' I�, BiI ��`�' "I�'Jl: il� IJI' XPJ '13 �'C �f Ql'IC: C
<br />.r :cr �;-rx•,s :•f,i�:p�iu= f-r,; �rT7'r;��i�xi�
<br />with the � of name and
<br />�96't r: � �i � :��iur's r�a�-ir. �rr; a�r�r•=:�::7Y�1'G�i
<br />a�b rerr�inp�.�t�
<br />Private data about you are available only to
<br />l�it' �O��WTtJ �7%���� i�7Gr?1per5 ylr.IrOFL'1�
<br />Eq�r4 ri-r_� ti10fK ass�nnen*.req� r fi� t7af
<br />thev haye access to t�e iniarmatinn; the
<br />Minnesota Department of Public Safety; the
<br />Minr�esotaRttomey General: the Minnesota
<br />Commissioners ofAdministralio�, Finance.
<br />and Revenue; the Minnesota Legislative
<br />Auditor, national and international garnbling
<br />-r,� a�:�l::rti• ��y{'rr?� F�ti�•a�� � �i���i•I I_ -:,r�i`
<br />ry�6rr: o!Ir_r uMiir-r�r.s nrd ��r.�r� �h .r. x��
<br />specifica liy authorized by state or federai iaw
<br />to have acce�s ta the infnrmation; individuals
<br />and agencies for which law or legal order
<br />authorizes a new use or sharing of information
<br />afterthis Notice was given: and anyonewith
<br />your consent,
<br />
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