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Minnesota Lawful Gambling <br />�.�22Q Application for Exempt Permit Fee $50 <br />An exempt permit may be issued to nonprofit organizations <br />conducting lawful gambling activity on five or fewer days, and <br />awarding lessthan $50,000 Ill prizes during a calendar year. <br />Organization Information <br />�rganfzation legal name <br />.��ee[ <br />�?�� ���r�,r���rt�, ,�4r�� <br />Name of chief executive offiGer (CEO) <br />First name <br />Page 1 af 2 11/04 <br />For Board Use Only <br />Fee Paid <br />Check No. <br />Previous license or exemption number, if any <br />F� +� ��,4? � a`F� � --- • - - -- <br />�� 5��'� end rp ea�e �a.�1X <br />�,��*'� ��� �?� ,�� � �� . J i�r��� � <br />Last name <br />Daytime phone nu <br />T��e of nonprofit organization (check one) <br />❑ Fraternal � Religious <br />� Veteran � Other nonprofit organization <br />Type Of proof of nonprofit m attach a Copy (see instructions) <br />�] Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's C3fFECE <br />� Internal Revenue Service <br />� Affiliate of parent nonprofit organization (charter) <br />Gamblin� Premises Information <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing wili take place) <br />.����..���.. -��� �i.�{ �.��'� �? _ <br />i�d�,r��s {da nol �ae PCI b�d�� �fhr ��p COde <br />�-�o � ���'��� r�� �+��= � {;������c. � .�.�� �� _ <br />f7ate(s) of activity (for raffles, indicate the date of the drawing) <br />��:X���f�i r� d'���i 1 <br />CheCk the box or boxes that indicate the type of gambling activity your organization will be conducting: <br />� *Bingo � F?�s ❑ 'Paddlewheels � *Pull-Tabs ❑ �`l`ipboards <br />���� <br />�� <br />'Gambling equipmentforpull-tabs,tipboards, paddlewheels, andbingo(bingopaper, hardcards,andbingoball <br />selection device) must be obtained from a distributor licensed by the Gambling Control Board. Tofind a licensed <br />distributor.. ao towww.gCb.skate.mn.us and clickon ListofLicensed 17istribvtor5. Orcall651-639-4000. <br />Thisformwill be made available in alternative <br />format (i.e. large print, Braille) upon request. <br />The information reauested on thisform (and <br />anyat�achments)wi[16eusEdlti} Ihrz[:�nr.'i� <br />Control Board (Board) to determine your <br />qualificationsto be involved in lawfulgambling <br />activitiesinMinnesota. Youhavetherightto <br />refuse to supp9y 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 />conseauence. may refuse to issue you a <br />��rind if you supply the inforrnation <br />requested, the Board wilE be able to process <br />krJur apr.l�'an_ <br />Your name and and your organization's name <br />and addresswill be publicinformation when <br />received bythe 6oard. Alltheotherinfomation <br />thatyou provide w:l be privatedata aboutyou <br />until the Board issuesyour permit. When the <br />Board issues your permik, all ofthe information <br />that you have provided to the Board in the <br />processofapplying foryourpermitwillbecame <br />public. If the Board does not issue you a <br />permit, all the information you have provided <br />in the process ofapplyingfora permit remains <br />private, with the exception of your name and <br />yourorganization's name and addresswhich <br />will remain public. <br />Private data about you are available oniy to <br />�h� ?�!I���,irys Rr3r:: r�ar�tnr:, s��sR �r 17e <br />Boara whose eti or� ass �nment req.tires G,�'I <br />tney hare access �� !ne information; ��� <br />M nnesota Depar�ment of P �o ic 5afe!y, the <br />Minnesot� AEto�neY General; the Minnescst� <br />� �rmr-� oners �f �.ynristraharr, Finance, <br />ana Robtriuc tnt �a��n�sai� �eg+s-�hva <br />Auditor, nationaland internationalgambling <br />regulatory agencies; anyone pursuant;ta court <br />order; otherindividualsand agenciesthat are <br />specificallyauthorizedby.state orfederal law <br />to have accessto the information; individuals <br />and aaencies for which law or legal order <br />authprizes a new use orsharing of infarmatior� <br />afterthis Noticewas given; and anyonewith <br />yourconsent. <br />