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Minnesota Lawful Gambling <br />LG220 Application for Exem <br />Permit Fee $50 <br />—An exempt perrrtit may be issued to rtonprofit Organizations — <br />conducting'lawful ga.�7�=n[� activity on five or fewer days, and <br />awarding less than $50,000 in prizes during a calendar year. <br />�rganizatiar� Information <br />I'age 1 nf2 1�104 <br />�or Soard Use Only <br />� Tee Paid_ <br />lCheck No. <br />�'rganization legal name a_ Previous iicense or exemption number, if any <br />�� • 5 <br />' v���u'��'}����� �� r ��� ���� �� x ��� Sr� , i�` _ ? z�;��; �� <br />�Rf�¢� � City State and zip code J County <br />_ f� �i l�- �y �F�r .�i�'Y ll� C� � ') ' 1,. '7' �'' �1 <br />�r- G���-���' � �c�r,r��� t -�t• - - `� * � <br />•�lame of chief executive bfficer (CEO) � � <br />Firstname Lastname � Daytimephonenumber <br />f���r�r Y .-t f•[-r �' ;�„ri l�G'�— -- r.�•��:� �'r' — 1; -- <br />- ��.. �-:.-� � , � . ', , �t :� <br />� lype 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 Off�iCe <br />� Internai Revenue Service <br />� Y It�li�lt of parent nonprofit organization (charter) <br />f k . <br />GamblingPremises Information <br />hlarrEe of premises where gambling activity will be conducted (for raffles, list the site where the drawing wili take place) <br />1 <br />� ' � <br />--� .:� 7 ��w'��'�G,f: 4 t ;•� �L•• � ��'� �• � � _ - — — • — -- — - <br />F.�dr�5s [d� MS u:e F� k�� '�r5' Zp [xa4e <br />I{f �� r <br />�4�r �i+' �r�,'�'� f��l �� �L �,'•� �,rF f� �'�..'1�,� � � i� �� <br />l}s I[�! s j af 2diM�y �f�or rafP•�s in:'::a'e Gio d�yl� pf II ��• rir���n�:�r�; '— — --� - • <br />� �i� r� G� <br />� �•�� . . .. <br />k�eck the box or boxes that indicate the type of gambling activity your organization wiil be conducting: <br />�� � c:�r� 4� � d <br />❑'Bingo �f�,tl,; r ❑ *Paddlewheels ❑ 'Puli-Tabs � *Tipboards <br />'Gamblingequipmentforpull-tabs, tipboards, paddlewheels,andbingo(bingopaper, hard cards, and bingo ball <br />selection device) must be obtained from a distributor licensed by the Gambling Controi Board. To find a licensed <br />distributor, gotowww.gcb.state.mn.usand click on Listof Licensed Distributors. Orcall 651-639-4000. <br />This Forrnwill be made available in alternative <br />format�� �. large print. Braille) upon request. <br />The informationrequested on this form (and <br />any attachments)will be used by the Gambling <br />Control Board (Board) to determine your <br />qualifications to be involvedin lawful gambling <br />activitiesin 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 vou supply the information <br />req uested, the Board will be able to process <br />your application. <br />Yourname and and �, �,.�� r.� •a:: •��r.��i::��'•. name <br />and addresswiil be public informationwhen <br />receivedbythe Board! All the other information <br />m�a�a� F� ; v�: ti�r. SEr�-,ase dara aaoLt ��:� <br />un4- r�,&� [�:�r! rs�-�pc p�,�r pvrr3'iil. �'�lxu IITe <br />Board issues vd ur pannit. a4I of the information <br />that you havk provided to the Board in the <br />process ofappiyingfor yourpermitwill become <br />public. If the Board does not issue you a <br />oermit. all the informationyou have provided <br />� � U�� ��:��r.L{�!T�j�n_ iGr �� r�-r-rF mT.Ts <br />^rrc{71[�. �'� t�C��� =^i v' � t �i �7:11'I_' 'J� J <br />yourorganization'sname andaddresswhich <br />will remain public. <br />Private data about you are available only to <br />the {oqQ,,,���g; Board members_ staff of tbe <br />Board whose work assignment requiresthat <br />they have access to the information; tile <br />Minnesota Departmentof Public Safety: the <br />MinnesotaAttorney General: the Minnesota <br />Commissionersof Administration. Finance, <br />and Revenue: the Minnesota Legislative <br />Auditor, national and international gambling <br />reguiatoryagencies;anyone pursuant to court <br />order; otherindividualsand agenciesthatare <br />specifically authorizedbystateorfederallaw <br />to have accessto the information: individuals <br />and agencies for which law or legal order <br />authorizesa new use or sharing of informalion <br />afterthis Noticewas given: and anyonewith <br />yourconsent. <br />