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i.G2�0. - Application f�r� Exempt Permit Fee -$25 ���a� <br />Or anization Information �� r�� <br />�rganization name Previouslawf��l�amf�ling exemption number <br />�T. ROSE OIF LYMA CHURCH <br />3t��� ' �� State/Zip Code County <br />2048 HAMLINE AUE . N. ����ii,i.F ���113 R�I��Y <br />Vame of chief executive officer (CEO) � <br />Daytir� p��u�pp�rofCEO <br />FTr�e �1 � 651-645-9389 <br />Vame of treasurer Daytime phone number of <br />First name Last name treasurer: <br />Type of Nonprofit Organization <br />Check the boxthat bestdescribesyour organization: <br />0 Fraternal � Religious <br />❑ Veteran ❑ Othernonprof�t organization <br />check the boxthat indicatesthe type of proofyour organization attached to this application: <br />�,IRS letter indicating income tax exempt status <br />� Certificate c�'Good Standing from the Minnesota Secretary of State's Office <br />� A charter showing you are an affiliate of a parent nonprofit organization <br />Q Proof previously submitted and on file with the Gambling Control Board � <br />Gamblin Premises Information <br />Vame of premises where gambling a c t i iw�ll be conducted (for raffles, listthe sitewhere the drawing will take place) <br />ST. ROSE OF LINN�,. SCHOOL <br />4ddress (do not use PO box) C�Y State2ip Code Couniy <br />2072 HAMI.IN� AVE. l�i ROSEViLLE MN 55113 RAMSEY <br />�ate(s) of a c t i i(forraffles, indicatethe date ofthe drawing) <br />SEPTEMBER 29, 2002 <br />�heck the box or boxes that indicate the iype of gambling a c t i i your organization will be conducting: <br />� 'Bingo � Raffles (cash prizes may not exceed $12,000) � 'Paddlewheels � 'Pull-Tabs � `Tipboards <br />�4 for these activities rr�ust be obtained from a licensed d�0 <br />This form will be made available in Your name and and vour �� =������� <br />alternative format (i.e. large grinf, Braille) <br />upon request. The information requested <br />on this form (and any attachments) will be <br />used by the Gambling Control Board <br />(Board)to determineyourqualifications to <br />be involved in lawful gambling activities in <br />Minnesota. You havethe rightto refuseto <br />supplythe informationrequested; however, <br />ifyou refuseto suppiythis information,the <br />Board may not be able to determineyour <br />qualrfications and, as a consequence, may <br />refuseto issueyou a permit. Ifyou suppiy <br />the information requested, the Board will <br />be able to process your application. <br />name and address wiq be pubric information <br />when received bythe Board. All the other <br />informationthatyou providewill be private <br />dataaboutyou untilthe Board issuesyour <br />permit. When the Board issues your <br />permit, allofthe informationthatyou have <br />provided to the Board in the process of <br />applyingforyourpermitwill becomepublic. <br />If the Board does not issue you a permit; <br />allthe informationyou haveprovided inthe <br />process of applying for a permit remalns <br />private, with the exception of your-name <br />andyourorganization's name and address <br />which will remain public. <br />Privatedata aboutyou are available oniyto <br />Board whose work assfgnment requfres <br />that they have access to the information; <br />the MinnesotaDepartmentofPubliiSafeiy; <br />the Minnesota Attorney General; the <br />Minnesota Commissioners of <br />Administration, Finance, and Revenue; the <br />MinnesotaLeglslative,�udil�, national and <br />internationalgambling regulatoryagencies; <br />anyone pursuant to court order; other <br />Individuals and agencies that are <br />specifica�y authorized by state or federal <br />law to have access to the information; <br />individu8ls and agencies for which law or <br />legal order authorizes a new use or sharing <br />af informationafterthis Noticewas given; <br />and anyone with your consent. <br />