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FEB, 4,2004 11:41AM TWIN CITIES HABITAT <br />Minnesota Lawful Gamhling <br />L�220 Application f�r Exempt Permit Fee $50 <br />N0, 8 2 4 F. 3 <br />Page 1 of 2(web) 12/03 <br />For Board Use Only <br />Fee Pald <br />Organizationlnformation I CheckNo. <br />�rgeni =�����R�"^`' Prevldus lawful gambling exemption number <br />�� ���5 � ��M'M����4 <br />� ����� � ��� �� �����' ��� �� �+_ <br />Name of chief execuGve afficer (CEO) { � <br />F na ,a �,�,� Daytime phone number of CEO <br />G i+� ' 3��—���f� <br />Name of' treasurer <br />C�LB�� <br />Daytime phone numberof <br />tteasur�r. <br />C� � r�l <br />Type of Nonprofit Organization <br />Checic the box that best describesyour organization: I � <br />�] Fraternal � Religious <br />� Veteran � Oth@C nonprofit organization ' <br />Checkthe box that indicates ��type of proot your organization attached to this�p�lbr� <br />[�] It�S ietter indiceting income tax exempt status �•�•�� <br />,❑ Certificate of Goad Standing from the Minnesota 5ecretary of State's 4��'�e <br />A chs�ter showing you are an atti�iate of a parent nonprofit organization <br />� Proof previousiy submitted and on file with the �ambiing �����i Board � <br />G�mblins_a Premises lnformat�on <br />ame orprem <br />will be cqndUCt6d <br />4 <br />Address (do not use PO box) ��yr � <br />��� 1 ��G"E� ��� �� ���f I�� <br />G31�L�; 8? e�I"r�i�' {hd�+�iF��� iM1��t�E#1I'ia d�'� a'f715± q•mnir;; <br />willtakeplace) <br />State/Zip Code County <br />� ���� � � ���� <br />7 � �� . ., . <br />Checkthe boxor boxesthat indicate th61yp8 ofgambling 9CtiVityyourorganization will be �p�dUCtlllg� <br />� '6irlgo � R2ffies (t9sh prz�may notzxGEisd $12,000) �'PBddlewheels �'Puli-Tabs � "Tipboands <br />'Gambling equipmentforpull-tabs,tipboards,paddlewheels,andbingo(bingopaper,hardcards,andbingoball <br />selection device)must�o��dilledf�p111adistributorlicensed bytheGambling��tC��l.B��� ?���n�a licensed <br />distributor, go to'�'r.�n'.���,��a7�.mn.us and GIyCk 011 LiSt Of Licensed Distributors, Orcall 651.6394000. <br />1 : n � JDp I avi'{abje in �ITerr�pttve l`v�r t : e� yv�r orysl'+�Gan's name <br />format{i.e, large print, Braille)upon roquest. and addresswill be publlclnform9GOnwhen <br />ThelnformationrequestedonthisfOrm(and recelvodbyU�eBoard.Alltheotherinformation <br />anyattachments)willbeu�by�eGambling thatyouprovidswillbeprivated8taaboutyou <br />COttt�01 Board (Board) tp determino your untiltheBoardissuesyourpertnit. Whenthe <br />qua�ificatlons4dt�involvedinl��,�gambling Boardissuesyourperm�kgqoftheinformation <br />activtties In Minnesols. You have the right to that }�.� have provided to the Board In tho <br />refuse to supply the informatlanrequested; processofapplyingfaryourpormiCwillbeoome <br />however, if ypu refute to supply this public_ ]f the Board ��# not Issue you a <br />�nformatlon, the Board may not be able to permit,alltheinformatlonyouhavgprovided <br />dete►m�ne your quaiitications and, as a intheprocessofapplyingforapermitremains <br />consequence, may refusa to Issue, you a p���d�6,with the exceptionofyourname and <br />permit. IfyoU SGAplythe information your0�g8niZetiOn'snameandaddresswhlch <br />requested, the Board wlll be ab�0 bG process ; will remaln pub��c. <br />yourappliCation. Private data about yoU 0r�+ available only to <br />the following: H+�er� �s�ens, ��I of l�1� <br />�vardwhose work asslgnment requiresthat <br />they have access �to the informadon: piQ <br />Mf nne5ot8 Department of Public Safety; the <br />Minnesota.�Fharrrr.'?�en�9ral; the Minnesoha <br />CoirimissiongrrT Of Admi��atration, Finance, <br />and Revenue; the Mlnnesota Leg�s�ative <br />Auditor, nationaland Intemationaf gambling <br />regu�atoryragenGes; anyone pursuar�tto tburt <br />order: otherindsv{dUalSandagenciesthatare <br />specifically authorized by St9te orfed eral law <br />to have accessto the Information; individuals <br />and agencies far whlch law or legal vr�ier <br />autho�lzes a new �s6 ar sharing off:�F�r. q��, <br />2fte� Ihls NOtiG£ W95 giVett; and anyone � <br />your conser�t, <br />