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Minnesota LawFul Gambling I C;77t1 � nnlicatinn fnr Fxam nt Parm it Fnn ��fl Page 1 pf 2 11104 ��_._._ - -rr.._�_._.. .—• ----...�_ . _....._ . .... .,...., For Board Use Only An exempt permit may be issued to nonprofit organizations conducting lawfui �am�llfl� activity on ftVe or fewer days, and FeePaid awarding lessthan $50.00Oin prizes during a calendaryear. CheckNo. Organization Information Organization le al name Previous license or exemption number, if any Roseville �entz'a1 Parlc Foundation X-62038 Street City State and zip code County 2660 Civic Center Drive �Zos�ville Mr� 55113 Ramsey Name of chief executive officer (CEO) First name Last name � Da��t�*ne phone number Monty Johnson � �a� 1 490-9411 Type of nonprofit organization (check one) ❑ Fraternal � Religious ❑ Veteran Q Other nonprofit organization Type of proof of nonprofit - attach a copy (see instructions) ❑ Nonprofit Articles of (nCOrporatiQn or Certificate of Good Standing - Minnesota Secretary of State's OffiCe � Internal Revenue Service � Affiliate of parent nonprofit organization (charter) Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place} Roseville Skating Center Community Room Address (do not use PO box) City Zip code County 2661 Civic Center Drive Roseville ��n 55113 Ramsey Date(s) of activity (for raffles, indicate the date of the drawing) October 21,2005 Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ❑'Bingo [� Raffles � "Paddlewheels ❑ 'Pull-Tabs � "�ipbnards 'Gambling equipmentforpull-tabs,tipboards, paddlewheeis,andbingo(bingopaper,hardcards,andbingoball selection device) must be obtained from a distributor licensed bythe Gambling Control Board. To find a licensed distri butor, go to wvvvv.gcb.staie.mn.us a n d cl i ck o n Li st of Licensed Distri butors. Or call 659 -639-dQOQ. Thistanmw+�"�� i� $ra4e�'� n aStesrcatr�re Y^_is �tcs� tiiaj aao f� • n�rtjgriz�l�r ; �r��+r� lh�+f9Y+�JY1R� k�v rnar��. s�tr ��n IFf11�1(�.� Ipf�t9�fE111, BfiI11Cf LIpOf1 'L'+.�4C5: he requestedon this forrrt (and ariy attachments}will be usedU� �ir_� C r��tJng Control Board (Board) to determine your qualificationsto be invplved in lawFulgambling activities in Minnesota. You have the right to refuse to supply the infnrmatior€ requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. !f you supply the information requested, the Board will be able to process your application. .anp �vorcss win rx pvoi�m�yNTr�t�f+5R1r� received bY the 8oard. Alltheotheririformation thatyou providewill be private data about you untiltheBoardissuesyourpermit. Whenthe Board issuesyour permit, all ofthe iriformation that you have providedto the Board in the processofapplyi n�wyour Permit wil[ bemme public. If the Board does not issue you a permit, allthe iriformationyou have provided i n the prooess ofapplyingfvr a permit remains private, with the exception oF your name and yausorganization's name and addresswhich will remain public. Private data about you are available only to r�aa� w n�-� �w`br4i �4�c$nrr�ns r�qd+res �rSE they have ac��.s YQ the information; the iVlinnesota Department of Pubfic 5afety, the MinnesotaAttorney General: the Minnesota Commissionen ofAdministration, Finance. and Revenue; the Minnesota Legislative Auditor, national and iriternational gambling regulatory agencies; anyone pursuanttr� cou€t order, otherindividualsandagenciesthatare speafically authorized b� state orfederal law to have a� to the iriformation; individuais and agenaes for which law or legal order authorizes a ne✓v use or sharing oF iriformation afler this Notice wasgiven; and ariyone with your conser�t.