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Minnesota Lawful Gambling LG220 - Application for Exempt Permit Organization Information Organization name �:�iV"ll�f' I I II �L�1PYi.'�l� Street " ��C�� ,�;! ��*'' ��- Name of chief executive officer (CEO) First name Name of treasurer �irst nam� C' y �� i 0�4X Type o'f Nonprofit Organization Last name Last name 1 1 Page 1 of 2 3/01 Fee ' �Z.J Fee Paid ' Check No, us lawful gambling exemption number State/Zip Code County S> 5111�`� ,'�+l ► �,�� Daytime phone number of CEO L'l�`� .' -S i L'S � ��-i— Daytime phone number of trea^surer: ^ W V � - ._/41.w - � �/f � 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 [v]' Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information ame of premises w ere gam ing activity wi � 1 r� .�c.. �-�-� I Address (do not use PO box) City �ite wnere tne arawing wu� taKe p�� State/Zip Code County �s�t� /�lce,� Ck:-�k� ��v�il,� Mn( �jSlr� 1�m� �ate(s) of activity (for rafFles, indicate the date of the drawing) Ndi�e.�-�b�e�e �D , �GD�- �u.-� cb� y �heCk the box or boxes that indicate the type of gamb�ing activity your organization Will be conducting: ❑ 'Bingo ❑ Raffles (cash prizes may not exceed $12,000) ❑ 'Paddlewheels ❑ 'pull-Tabs �'Tipboards� Eauiament for these activities must be obtained from a licensed distributor. This form will be made available in Your name and and your ori �anization's tne tonowmg: tsoara memtiers, statt or tne alternative format (i.e. large print, Braille) name and address will be public information Board whose W�ark assignment requires upon request. The information requested when received by the Board. All the other that they have access to the information; on this form (and any attachments) will be infOmlati0n that you provide will be private the Minnesota Department of Public Safety; used by the Gambling Control Board data about you until the Board issues your the Minnesota Attorney General; the (Board) to determine your qualifications to permit. When the Board issues your Minnesota Commissioners. of be involved in lawful gambling activities in permit, all of the information that you have Administration, Finance, and Revenue; the Minnesota. You have the right to refuse to provided to the Board in the process of Minnesota Legislative Auditor, national and supply the information requested; however, applying for your permit will become public. international gambling regulatory agencies: if you refuse to supply this information, the If the Board does not issue you a permit, anyone pursuant to court order; other Board may not be able to determine your all the information you have provided in the individuals and agencies that are qualifications and, as a consequence, may process of applying for a permit remains specifically authorized by state or federal refuse to issue you a permit. If you supply private, with the exception of your name law to have access to the information; the information requested, the Board will and your organization's name and address individuals and agencies for which law or be able to process your application. which will remain public. legal order authorizes a new use or sharing Pri�ate data about you are a�ailable only to of information after this Notice was given: and anyone with your consent.