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Minnesota Lawful Gambling <br />LG220 Application ��r Exempt Permit Fee $50 <br />Organization Information <br />Organization name <br />���� � � ��� � <br />�1r4et <br />� �� l �I . �--��r��� �: � �a <br />Name of chief executive officer (CEO) <br />First name � <br />� ���� <br />l�i� �f�'f�1�!'�'� ,,J <br />��� �w� <br />� 5 �+..� �i c� � <br />Last name <br />��� <br />Name of treasurer <br />First name � � Last name �/ �� <br />�' r �� y� <br />Type of Nonprofit Organization <br />Page 1 of 2(web) 12/03 <br />Fee <br />I Check No. — <br />ous lawful gamblingexemption num <br />��" '�'��.. ` ��` � — — <br />�41�i� �� ��1y+ <br />��'+�{� ��.��� � <br />4�ay��rn� h�nQ �+�mGQr 4� �E� <br />��� ��� �-t�r� <br />Daytime phone number of <br />treasurer: �� •� _ �� <br />� ���; <br />Check the box that best describes your organization: <br />❑ Fraternal Religious <br />❑ Veteran Other nonprofit organization <br />Check the box that indicates the type of proof your organization attached to this application: <br />❑ IlZS letter indicating income tax exempt status <br />eCertificate of Good Standing from the Minnesota Secretary of State's Office <br />A charter showing you are an affiliate of a parent nonprofit organization <br />[� Proof previously submitted and on file with the Gambling Control Board <br />Gamblina Premises Information <br />ame or premises <br />wi <br />�#�* �+-, � ,�� .� _�{� ~' � �� <br />Address (do not use PO box) ��y <br />��C% � f-�..c�rS�� +��- ��Si���� <br />Date(s)ofactivitv(forraffles. indicatethedateofthedrawinal <br />isttne site wneretne arawinawui taKe piace <br />StatelZipCode County <br />� �'�� � ,� ��.,+�� �� <br />—� �*-'�, ��� ����� <br />Checkthe box or boxesthatl�lr�l4thetypeof gamblingactivityyourorganizationwill be conducting: <br />� 'Bingo � Raffles(cash prizes may not exceed $12,000) � *Paddlewheels �'�ul�Ta'�� �'Tipboards <br />"Gamblingequipmentforpull-tabs,tipboards, paddlewheels, andbingo(bingopaper, har cards, andbingoball <br />selection device) must be obtainedfrom a distributorlicensed by the Gambling Control Board. To find a licensed <br />distributor, go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or ca11651-6394000. <br />' fx � I F f�61� � alCemafive <br />Ie <br />format (i.e. large print, Braill e) upon request. <br />Theinformation requestedonthisform (and <br />any attachmenis) will be used k� the Gambli ng <br />Control Board (Board) to determine your <br />qualificationsto be involvedi n lawFul gambling <br />activitiesinMinnesota. Youhavetherightto <br />refuseto supply the information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able to <br />determine your qualifications and. as a <br />consequence, may refuse to issue you a <br />permit. If you supply the information <br />requested, the Board will be able to process <br />your application. <br />f�f R7f1"� il10 i'i4}'�r o-�Ma�� I$�i <br />and addresswill be p�hG4informationwhen <br />receivedk�theBoard. Alltheotherinformation <br />thatyou providewill be privatedata aboutyou <br />untiltheBoardissuesyourpermit. Whenthe <br />Boardissuesyourpermit, all oftheinformation <br />that you have provided to the Board i n the <br />process of applyingfor your permitwill become <br />public. If the Board does not issue you a <br />permit, alltheinformationyouhaveprovided <br />i n the process of applyingfor a permit remains <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 />�v�k►g: � l i n o1 the <br />Board whose work assignment requires that <br />they have access to the information; the <br />Minnesota Department of Public Safety; the <br />MinnesotaAttorneyGeneral; the Minnesota <br />Commissionersof Administration, Finance, <br />and Revenue; the Minnesota Legislative <br />Auditor, national and international gambling <br />regulatoryagenaes; anyonepursuantto court <br />order; otherindividualsandagenaesthatare <br />specificallyauthorizad hy staterrfPCleral law <br />to have accessto the information: individuals <br />and agencies for which law or legal order <br />authorizesa new use or sharing of information <br />aflerthis Noticewas given; and anyonewith <br />your consent. <br />