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<br />Minnesota Lawful Gambling
<br />�,G220 Application for Exempt Permit Fee $50
<br />An exempt permit may be issued to nonprofit organizations
<br />conducting lawful gambling activity on five orfewer days, and
<br />awarding lessthan $50,000 In prizesduring a calendar year.
<br />Organization Information
<br />Org&nlz2ti0n legal name
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<br />Street
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<br />Page 1 of 2 11104
<br />For Board Use Only
<br />Fee Paid
<br />Check No.
<br />Previous license or exemption number, if any
<br />City State and zip code County
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<br />7ype of nonprofit organization (check one)
<br />❑ Fraternal ❑ Religious
<br />❑ Veteran ❑ Other nonprofit organization
<br />i Type of proof of nonprofit - attach a copy (see instructions)
<br />1 ❑ Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office�
<br />_ � Internal Revenue Service
<br />: n Affiliate of parent nonprofit organization (charter)
<br />Gambling Premises Information
<br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place)
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<br />�ddres5 (do not use PO box) City Zip code
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<br />']aie(s} of activity (for raffles, indicate the date of the drawing)
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<br />MheCk the box or boxes i�at indicate I:� I; ::ti: of gambling activity your organization will be conducting:
<br />�'Bingo � Raffles � 'Paddlewheels � *Pull-Tabs � *Tipboatds
<br />County
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<br />This form will be made availablein alternative
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<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 you supply the information
<br />requested. the Board will be able to process
<br />your application.
<br />Yourname and and yourorganization'sname
<br />and address wiil be public information when
<br />receivedbythe Board. Alitheotherinformation
<br />that you provide will be private data about you
<br />until the Board issuesyour permit. When the
<br />Board issuesyour permit, all of the information
<br />that you have provided to the Board in the
<br />processof applying for your permitwill become
<br />public. If the Board does not issue you a
<br />permit, all the informationyou have provided
<br />inthe processofapplying fore permitremains
<br />private, with the exception of your name and
<br />yourorganization'sname and addresswhich
<br />will remain public.
<br />Private data about you are available only to
<br />the following: Board members, staff of !he
<br />Board whose work assignmentrequires that
<br />they have access to the information: the
<br />Minnesota DepartmentofPublicSafety; the
<br />Minnesota Attorney General: the Minnesota
<br />Commissioners ofAdministration, Finance.
<br />and Revenue: the Minnesota Legislative
<br />Auditor, national and international gambling
<br />regulaiory agencies; anyone pursuantto court
<br />order; otherindividualsandagenciesthatare
<br />specificallyauthorized by state orfederal law
<br />to have accessto the Information; individuals
<br />and agencies for which law or legal order
<br />authorizes a new use or sharing of information
<br />after this Notice wasgiven: and anyone with
<br />ypurconsent.
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