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� ,�; �:'` �;' �e�� ` � , • y,�. -� Page 1 of 2 3/01 Minnesota Lawful Gambling `� ro� eoa u$e �, y LG220 - Application for Exempt Permit Fee -$2 FeePaid �Organization Information Check No. Or anization name Previous lawful gambling exemption number ot'-�-�kl�.� r� ��'� Ce S :S t r e e t City State/Zip Code County � � `�V � � �� a ��V�► �� m�; ss � � �3 �c;�, Vame of chief executive officer (CEO) � First name Last name Daytime phone number of CEO �•�� c,�\,MbQr �OJ 1� �c - ��j ame of treasurer Daytime phone �umber of First name �ast name treasurar: "�c� lJ�' C� +�-�- (f11 - �51$- 3 ��o Type of Nonprofit Organization Check the box that best describes your organization: ❑ Fraternal ❑ Religious ❑ Veteran �] Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: � IRS letter indicating income tax exempt status Certificate of Good Standing from the Minnesota Secretary of State's Office ❑ A charter showing you are an affiliate of a parent nonprofit organization ❑ Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information Name of premises where gamblin activity will be conducted (for raffles, list e site where the ' g uvi�l take place) . M �� L. �n G � � ,S �c...� �� ('vtan C,1��.�.�1 � t' K'� �, 1 � i- Addl'eSS (do not use PO box) Cit�r Sta e2ip � ode County (.�� 5�� t� � �C=�� I � � tVW JJ � �Cc rnS� Date(s) of activity (for raffles, indicate the date of the drawing) �_�lA�' � � �� C-�.� � Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ❑ *Bingo �Raffles (cash prizes may not exceed $12,000) � "paddlewheels � *Pull-Tabs � "Tipboard: *Equipment for these activities must be obtained from a licensed distributor. This form will be made available in Your name and and vour oraanization's e o owing' oar mem ers, s a o e alternative format (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be invoived in lawful gambling activities in Minnesota. You have the right to refuse to supplythe information requested; however, if you refuse to supply this information, the Board may not be able to determine your quaiiications and, as a consequence, may refuse to issue you a permit. if you supply the information requested, the Board will be able to process your application. name and address will be pubh information when recei�ed by the Board. Ail the other information that you pro�ide will be pri�ate data about you until the Board issues your permit. When the Board issues your permit, ail of the information that you have provided to the Board in the process of applying for your permitwill become public. If the Board does not issue you a permit, ail the information you have provided in the process of applying for a permit remains private, with the exception of your name and your organization's name and address which will remain pub{ic. Private data about you are available only to ttoard wnose worK assignment requires that they have access to the information; the Minnesota Department of public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the Information; individuals and agencies for which law or el order authorizes a new use or sharing o information after this Notice was given; and anyone with your consent.