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Minnesota Lawfu! Gamblin Page1 of2 sio� g For Board Use Only LG220ApplicationforExemptPermit Fee•$25 Fee Paid �r anization information � �• )rgan'¢atbn narne PrBVious lawful gambling exemption number Roseville Central Park Foundation X-62038 3treet �� City State2ip Code County 1970 Oakcrest Ave. #118 Roseville Mn 5 5113 Ramsey ��11e of chief executive officer (CEO) F'ust name Lest name Daytime phone number of CEO Monty Johnson 651 490-94 11 Vame of treasurer Daytime phone number of Fifst name Last name treasurd: R Robert Matson 612 889-4463 Type of Nonprofit Organization Check the box that beet 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 ❑ C@t�I�CeI@ 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 eCtivliy will bp conducted (for raifles, list the site where the drawing will take place) Roseville Skating Center Community Room Address (do not use PO box) City State/Zip Code County 266 1 Civic Center Drive Roseville n 55113 Ramsey Date(s) of activity (for retAes, indicate the date of the drawing) October 4, 2002 Check the box or boxes that indicate the type of gambing activity your organization will be conducting: ❑ 'Bingo • (1 Raffles (cash prves may not exceed $12.000) � •paddlewheels � 'Pull-Tabs �'Tlpboatd;e 'Equipment for these activities must be obtained from a licensed distributor. This form will be made available in Your name and and your organization's alternative format (i.e. large print, Braille) name and addr+ess wi8 be public information upon request. The information requested when received by the Board. All the other on this form (and any attachments) w�1 be information that you provide wiU be private used by the Gambling Control Board data about you until the Board issues pur (Board) to determine youfquaifiqbonS to permit. When the Board issues your be involved in lawful gambling activities in permit, all of the information that you have Minnesota. You have the right to refuse to provided to the Board in the process of supply the infamiation requested; however, applying for your permit wiN become public. if you reiuse to supply this information, the If the Board does not issue you a p�pj�, Board may not be able to determine your aY the information you have provided in the qualifications and, as a consequence, may process of applying for a permit remains refuse to issue you a petm�, Ifyou supply private, with the �eption of your name the information requested, the Board will and Y'o�� organization's name and address be able to process your application. which will remain public. Private data 2b0ut you are available only to me roaowmg: tsoarq mem�ers, start ot tne Board �,�,hose work assignment �equires that they have access fo t�e information; the Minnesoia Departrnent of Pub4c SaFeiy, the Minnesota Attorney General; the Minnesota Commissioners of Administration, F�ance, and Re�renue; the Minnesota�episl�¢v�B AUdifOf, natinnal anr� intemaeon gambhng reguletoryagenaes; anyone pursuant to court order; other individuals and agencies that are sped6c�lly authorizsd by state or federal �W to have access to the informadon; �� and aqencies for �� law or legal order authoraas a new use or sharing Of IP1�(MBtIDl1 after this Notice was given; and anyone wifh your consent.