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Page 1 of 2 3/01 Minnesota Lawful Gambling or oar se n y LG220 - Application for Exempt Permi# Fee -$25 FeePald Organization Information cne� rvo. Organization name Previous lawful gambling exemption number �,� -t�..,.,r—_��c_�.c_ �= � c�-.r—_ T,`��; �,�.�e c..��-�` Street City State/Zip Code County �J�_(i �t 1�!- l_F��a�� ro�1 �:Ouc=;c�rc_c, _ ,5'S! 1 :.� .�`=�}rulSi. Name of chief executNe officer (CEO) Da time hone number of CEO First name Last name Y p �; ,�►.1 ��,�;: �.. C-� �— t�'3�;�- G�/a'_� Name of treasurer Daytime phone number of First name Last name treasurer: ��,��ti�S =�j�,��sc �.��i ;,s/- ��/ _ -l��`/S 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 gambling activity will be conducted (for raffles, list the site where the drawing will take place) tiD ; ' ��..�e, � � = t�1 �a,,—� 0 �J � 4 Address (do not use PO box) City State/Zip Code County �"�c� t 1v • LEic�tihTa �` ��:�'� �v I �..�.�,::_ l�l►3 ,_ � S I � � �►Z�r�s,i:� Date(s) of acCMty (for raffles, indicate the date of the drawing) C:�cz- � �'"` 7�c.� � Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ❑*Bingo � Raffles (cash priies may not exceed $12,000) ❑ 'Paddlewheels � *Pull-Tabs Q'Tipboards 'Equipment for these activities must be obtained from a licensed distributor. This form will be made available in Your name and and vour oraanization��e toibwmg:�o3ftl rYiemOers. S[2tT oPth 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 involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be ab�e to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you suppIy the information requested, the Board wi� be able to process your application. name and address will be public information when received by the Board. All the other information that you provide will be private data about you until the Board i�sues your permit. When the Board issues your pen-nit, af1 of the information that you have provided to the Board in the process of applying for your permit will become public. If the Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains private, with the exception of your name and yourorgan'izafion's name and address which will remain public. Private data about you are available only to tiOafQ w��5e wofK assignmen[requ�res that they have access to the information; the Minnesota Department of PubGc 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 legal orderauthor¢es a new use or sharing of information after this Notice was given: and anyone with your consent.