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Minnesota L.��'uf Gamblir�g Page 1 of 2 2106 L�� 0 �4p��# i �� rr� �# �er��t ��e �� For Board l]sc �aly �r.r�,�rl An exemptpermitmaybe issued to a nonprofitorganization conducting iawfui gambling activityon five or fewerdays, and Check No awarding less than $50,0€�t3 in prizes d u ri ng a caiendaryear. � �rgani��tion Information Organization name Previous IawfuEctatr�b{ing exemption number Rosevi�L� Central Park Foundation Street �'-:}' State/�ip Code County 2660 Civic Center Drive Roseville MN 55113 Ramse ;�:�me �f chi�'- ��rlNl� ��:; . Daytime phone number r irsl n�:�� .—._.. I:,t,l � �:�i �� ��artE� �O�l[L��£1 . Type of Nonprofit Organization 7ype of nonprofit organization (check one) ❑ Fraternai � Religious � Veteran � Other nonprofit organization Type of proof of nonprofit status -attach a copy (see instructions) ❑ Nonprofit Articles of incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office � internal Revenue Service (� Affiliate of parent nonprofit organization (charter) ❑ Proof previously submitted and on file with the Gambiing Control Board Gambling Premises Information �lame of premises where gambiing activitywill be cond ucted (for raffles, iist the site where the d rawing wili take place) Rosev%lle Skating Center Community Room Address (do not use PO box) City Zip Code County 2661 Civic Center Drive Rc�seville MN 55113 Raz�sey bat�(s} of activity (for raffles, indicate the date of the drawing) October 6 2006 Chec€cthe box or boxes that indicate the type of gamblingactivityyour organizationwil� be conducting: � 'Bingo � Raffles � '"Paddfewheels ❑'Pull-Tabs �'Tipboards 'Gambling equipmentfor pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb.s#ate.mn.�sand click on List of Licensed Distributors. Or call 651-639-4000. "fhis forrn will be made avaiiable in aiternative Your name ar�c4 and Your organization's name the foilowina: Board members, staff of the forrnat (i.a. large print, Braille) upon request. The information requested on this forrn (and anyattachments)wiii be used by the Gambling Control Board (Board) to determine your qualificationstobe involved in iawfuigambiing activitiesin Minnesota. You have the rightto refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will be abie to process your application. and address wili be pubiic information when received by the Board. Ail the other inforrnation thatyou provide will be privatedata about you untii the Board issuesyour permit. When the Board issues your permit, al� of the information that you have provided to the Board in the process of applyingfor your perrnit wili become pubiic. if the Board does not issue you a permit, alithe informationyou have provided in the processofappiyingfora permitremains private, with the exception of your name and your organization's name and addresswhich wili remain pubiic. Private data about you are available only to Board whose worlc assignment requ ires that they have access to the information; the Minnesota Departmentof Pubiic Safety; the MinnesotaAttorneyGeneral; the Minnesota CommissionersofAdministration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambiing regulatory agencies; anyone pursuant to court order; other individuais and agencies that are specificaiiy authorized by state orfederai law to have access to the information; individuais and agencies for which law or iegal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.