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���� ��� � <br />���lr?���� Z�ii�t#� ����+� <br />L� ��0 �� �R���ti�� €o� �x�m �t � � rm M# ��� <br />�; i�K�!17� �?Tf' i�T13X' v9 19E+J0^ 1:� 3 f'�4fl�f �'�fF D'�8f11�8LOf1 <br />::�7r74'JC�II"� I�'�f�Lll L�$T.�,litl� �r.k'nrily br5 ��r� ar iEwucr d�ks �n:' <br />���.+e�dirr, Itee tfi&i5,��,C00 in �ti�e� duiii�g� 8�alqridar }+g±ef <br />Page 1 of 2 2/06 <br />a--�--- — <br />�. ��far B�sr�i iJ�c �iLy <br />F�� F$�- — <br />! �+�eCk �+b. <br />�h�gf1L��O1'y �i1���{Y��?lOT1 - .—...-- <br />t�;.�ani�,,�inr. n�,r�� Previous tavul iJgambling exemption number <br />���,���'r��� .���_���� ��+��_�.� �� ��'{�r�.— �' � �Ci! #� <br />- � — �-+�x f� - ' $�i � �',Os�� ?'i3W5h� — <br />r _ t� �_i� ����� __ . .— . ��. �'�� � _ '� ^F �-'�`�' <br />N�m� �t ehier ei�c-euFiv� afi'I� {C�t�7 <br />� Irat r.s�e LS31 F1�F77� <br />_ r�_ ff �� � J%���7�f�L <br />T�pe o# N���r�fl t� r�a n i�a��n <br />Type of nonprofit organization (check one) <br />� Fraternal ❑ Religious <br />� Veteran Other nonprofit organization <br />❑�Y�+�i� P�1dne nusrrtr�r <br />� <br />� <br />Type of proof of nclr�pt'ofit status -attach a copy (see instructions) <br />� Nonprofit Articles of Snearpora�tian or Certificate of Good Standing -(Vlin�t� sota Secretary of State's Office <br />� Internal Revenue 5�t�lice <br />�Affiliate of parent rto�sproft organization (charter) <br />Proof previously submitted and on file wi�h the Gambling Control Board <br />�Gambling Premises �r�f�r��tia� � <br />Nameofpremiseswheregarr�bl�ngactivitywElfbecoridyctecE(forraffles,listthesitewhere q-�odrawingwilitake p���,� <br />�����f��- l�f�'� �� ?"����� �-- — <br />Address (do not use PO box) City ��ip ��� : ��oun#y � <br />T` 7� / �r �- {- 3 � r r �r'. - �, � r�C 4 �{ �`• ��� � �_�f �. y._�- !. �� r' �'�'�� ] ; <br />Date(s} af activity (for raffles, indicate tlle datie ofthedrawing) .�, <br />{� ' r ti <br />��� � (f _� � f� __ �_`.r C L : � <br />r•- � <br />Checkthebox orboxesthatindicate e peo gam iing ac ivi yourorganiza ionwi e con uc ing: <br />� 'Bingo �Raffles [� "Paddlewheels �I'Pull•T�:� �f %Tipbaarca <br />*Gambling equipmentfor �aaat[ tab�,ti�►fs4ard�,gsadd4�v�fhee#s, and bingo (bingo pc�� aea�, hard cards, and bingo ball <br />selectiondevice)mustbeobtainedfromadistributorlicensedbytheGamblingC.��tr�iBoard. Tofind a�licensed <br />distributor, gotowuvuu.gcl�,stake.�n.t�sandclickonListofLicensedDistributors. d}rcall$�i'gKfi39•40E1�. <br />Ti�fi�'r'i7tiWlbg �e2veif8Hlei}�iRern2live <br />1�'�7� t�r. �dt.�r pr��t. I]rt �lel upon •cnues� <br />The information requested on this form (and <br />anY af�cl�r'nen#s) wifl be u�d by the Gamhling <br />�a[�i►o� 3 d {BOar� I�o {�L��f�ll+`� y�ur <br />qus��fiEafi^� � � ��aF,�J r�lgarnbLu� <br />activitiesin Minnesota. You have the rightto <br />refuse to supplythe 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 u.iH be able to process <br />your application. <br />Yd�IrABfi9 s+14 �7pn:ir nr��i'� �6�1� �br.�r. <br />and addwsa,nili � p�,F�!'r-++�n�sr�ii�,v'r�n <br />rar,�ived by the Board. All tit� atiier iriformation <br />thatvou �rovide wil[ be private dat� ��owt yo€a <br />F��� l���f# i.�,tee }�"�r f�tt9r �n tlte <br />E3�nr�aer�5�ow pe�:r� a3 oi�'� rrtfottnat� <br />that you have provided to the Board in the <br />process ofappiying f�ryour perrrrfEwift become <br />public. If the Board does not issue you a <br />permit, allthe informatin you have provided <br />intheprocessaf appfy€ng fora permit remains <br />pnvate, with theexception o�your name ar�d <br />your organization's�atT� a�1e4 addresswhich <br />will remain public. <br />Private data aboutyou are available only to <br />€#I" �iF"�Cal�ig: 5a y r��r� "� o#� <br />�; ara'.���x+n�s; d�fatdRl��1►i@ql�it�il�l-E <br />���,v have access to �q� i�€,��atior�: the <br />�9 ��nr_xr�� l�enartment n. R:il'�fr r,��Fr-� <br />h1 ��1�§� �€Eeffi$�r Ge �a�al:'I�? 11.'L9�e�1Fi <br />C• rrn:issi-n_rs aj �,n�nl��i. FlrArae, <br />�r � f�ven�se, 5ht A#innea� 3 �agiaJat►ve <br />A�•�iaor, �61E�o�l�+r,� �tsrnai4h-31 �bdng <br />rs� #utator�� agencies; anyone ��rrsuant to cau r� <br />or �r; nther ilndiv3du�is anc���,��•at� thatare <br />� ,�=aIF� authorized bys#at�.� orfederal law <br />to �iav�aac�sstotheinformation; individuals <br />at � ayencies for which law or legal order <br />a1 kharizes a ne,ro use orsharinc� ofi nfo mati on <br />�AP �f this Notice was �iv�n; �id anvone with <br />vc urccrnsent. <br />