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Minnesota Lawful Gambling <br />LG220 Application f�r Exempt Permit <br />Organizationlnformation <br />Organization name <br />Roseville Central Park Foundation <br />Street <br />Name of Chl@f executive officer (CEO) <br />First name <br />Name of treasurer <br />First name <br />City <br />Type of Nonprofit Organization <br />Last name <br />Last name <br />Ch eck the box that best describes your organization: <br />� Fraternal ❑ Religious <br />� Veteran � Other nonprofit organization <br />Fee $50 <br />Page 1 of 2(web) 12/03 <br />Fee Paid_ <br />Check No. <br />Previouslawful gambling exemption number <br />X-62038 <br />StBte/Zip Code County <br />Mn 55113 � <br />�ayl� a h�n sflber �t �.Eo <br />`� r � - .�-'�' - � � <br />f� Y� r4 J� fM1 J ti� <br />Daytime phone numberof <br />treasurer: <br />Checkthe box that indicates the type of proof your organization attached to this application: <br />IlZS letter indicating income tax exempt status <br />Certificate of Good Standing from the Minnesota Secretary of State's Office <br />A charter showing y0u are an affiliate of a parent nonprofit organization <br />Proot previously submitted and on file with the Gambling control Board <br />Gamblin�_Premises Information <br />— - -- -- �.,. . .r - -- . - <br />�rr�e�Fpr�rr�is�s �tr��rr�Trr� a��rW ba mr+�+� tkMr r� ����e�+e �h$ d��wk►p v� <br />Roseville Skating Center Community Room <br />Address(do notuse PO box) �,r <br />2661 Civic Center Drive Roseville <br />Date(s}ofactivity(forraffles, indicatethedateofthedrawing) <br />October 1, 2004 <br />State2ipCode County <br />Mn 55113 Ramsey <br />�:h� k �e k : ��rart�v���tir�a#��he � #f ' ' i � GI r y� _._.. ... . - - -• <br />� ���� � t <br />� 'Bingo � Raffles(cash prizesmaynotexceed$12,000) �'Paddlewheels � "Pull-Tabs �'Tipboards <br />'Gambling equipmentfor pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball <br />selection device) must be obtained from a dlstributorlicensed by the Gambling Control Board. To find a licensed <br />distributor, gotowww.gcb.state.mn.usandclickonListofUcensedDistributors. Orcall651�39-4000. <br />TYi� k willbemadeavailablelnaltemative <br />format(i.e. large print. Braille) upon request. <br />The informationrequested onthisform (and <br />any attachmenis) will be used bythe Gambling <br />Control Board (Board) to determine your <br />qualificationsto be involvedin lawful gambling <br />activitiesin Minnesota. You havethe rlghtto <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 wlll be able to process <br />yourapplication. <br />�'�n �r� � and yourorganfzation's name <br />and addresswilE be publicinformation when <br />receivedbytheBoard AlltheotherfnfortnaUon <br />thatyou providewill be prlvate data aboutyou <br />untiltheBoardissuesyourpermit. Whenthe <br />Board issues your pertnit, all ofthe Information <br />that you have provided to the Board (n the <br />process of applyingforyourperrnitwill become <br />public. If the Board does not Issue you a <br />permit, all the information you have provided <br />i n the process of applying for a permitremalns <br />private, withthe exceptionofyournameand <br />yourorganizati�'aname and addresswhich <br />willremainpublic. <br />Private data aboutyou are available only to <br />ibp folW�; Board members. staff of the <br />Board whose work assign mentrequiresthat <br />they have access to the Information; the <br />Minnesota Departmentof Public Safety; the <br />MinnesotaAttomeyGeneral; the Minnesota <br />CommissionersofAdministration, Finance, <br />and Revenue; the Mlnnesota Legislative <br />Auditor, nationaland internationalgambling <br />regulatory agencies; anyone pursuantto court <br />order, other individualsand agenciesthat are <br />speafically auth orizedby state or federal law <br />to have accessto the Information; individuals <br />and agencies for whtch law or legal order <br />autlhorizes a new use or sharing of information <br />afterthisNoticewasgiven; andanyonewith <br />yourconser�t. <br />