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� �1iil1�5�� wF�� rtx�bfr'� �� A��li��ti�r-� f�r ��m�t ��rrt�it �r�a rr��a�a�n � rr�� rr�,�tPa�r �� nizaL+�n na� �t. �s� �i L.�sa �atr�x] i�- c:l�,�r�h ',Street ' �048 Ha�t]_�,�e Av�.N. �/ame of chief executive officer (CEO) First name h�obert �/ame of treasurer First name C ity Roseville Last name P`itzpatrzck of Nonprofit Organization Last name �r Page 1 of 2 06/03 F�� I�w�ul�r �r�tial�ng easemp�ioe7 n�rlit�r r� nx Statelzip code County ]� 55113 Ramsey Daytime phone number of CEO Include area code Daytime phone numberof treasurer. Include area code Check the item that best describes your organization: _ Fraternal � Religious — Veteran _ Other nonprofit organization Check the item that indicates the type of proof your organization attached to this application: _ IRS letter indicating income tax exempt status _ Certificate of Good Standing from the Minnesota Secretary of State's Office _ A charter showing you are an affiliate of a parent nonprofit organization _g, Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information Name of premiseswhere gambling activitywil[ St. R�ise Of 'Lima School Address (do not use PO box) ��{ 2072 �aa�.��ne Ave. IS � Roseville Date(s) of activity (for raffles, i nd icate the date of the drawing) Oct. 1, 2006 atewneretne drawingwiu take p�ace) Statelzipcode County �IN 55113 Ram�ey Check the iterr�(s) that indicate the type of gambling activity yourorganization will be conducting: �C,_ 'Bingo _ Raffles(cash prizes may not exceed $12.000) _ "Paddlewheels � *Pul!-tabs _ *�'ipboards `Eq-i�+�:��i fvr tl�se �r'1rr.ii�* «us�l �a� �+b1;�v,�tr�rn a �r�n:� disiFibutor. :hi� f�rm vrlu :s� r,i�,� akapah��q � �`aii7.;�:•,��'.�,�;r�r.r��.�"erye�,rin�, �+,+il�t} ��.KsCi r�'i��`S� T,i� inf::rri'�Li�� 1��+� on thlS For ��7 ��r:l 3r��+ dttathrh�l53 rallkd� used by the Gambling Control Board (Board) todetermineyourqualifications to be involved in lawful gambling activitiesin Minnesota. Ycu have the right to refuse to supply the information requested; however, if you refuse to supply this inforrnation, the Board may not be ableto determineyour qualificationsar�d, as a consequence, may refuse to issue you a permit. If you supply the informationrequested, the Board will be able to process your application. Your name and and your organization's i�nc and arldress rriN be public �c�n �eo- rac�+a�a tx� t#ie �rrar�. �11 khe Nf�rr h�for�r�klt,n Ilidtl ytn; Ff�iw�� wili t.� private d2ka a�k }�eu ur,�l 4n� Board issues your permit. Wher� the Board issues your permit, all of the information that you have provided to the Board in the process of applyingforyour permitwill become publie. I f the Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are available only to the following: Board members, staff of the i�� '�� 1l�r. ��Pr.�$ � �,� !f?fA� � �tion; F� �iA��B� r�,�;�f;� r.�iat $� �i�� 52feE'�; [I w F1i?�i7��11� �I50� Il�' G2112f�; the Minnesota Commissioners of Administration, Finance, and Re✓erxae; the Minnesota LegislativeAuditor, nationaland intemational gambling regulatoryagenaes; anyone pursuant to court order, other individualsand agencies that are speci�caEly authonzed by state or federal law to have access to the information; individuals and agenaes for which law or legal order authorizes a new use or sharing of information after this Notice v� given; and anyone with your consent.