Agenda - Council - 07/22/2003 - Laserfiche WebLink

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Minnesota Lawful Gambling LG220 - Application for Exempt Permit _L S 2003 Fee- $25 Organization InformatiOn Organization name Street Page 1 of 2 8~00 For Board Use Only. Fee Paid Check No. Name of chief executive officer (CEO) First name Last name Name of treasurer First name Last name Previous lawful gambling exemption number o --.-¢3 _,:,¢ / IState/Zip Code J County :3' 1¢. i 'b mdc-: Daytime phone number of CEO Daytime phone number of treasurer: Type of Non profit 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 Gamblinc~ Premises Information Name of premises wl~ere gambling activity will be conducted (for raffles, list the site where the drawing will take place) Address (do not use PO box) City Date(s) of activity (for raffles, indicate the date of the drawing) )'~'!. ,'tState/Zip --'<'~'~ ~ ~ Code , County Y'~rl~.) I ~;~ Check the box or boxes that indicate the.type of gambling activit~ your organization will be conducting: [] 'Bingo ~ Raffles [] *Paddlewheels []*Puli-Tabs [~]*Tipboards *Equipment for these activities must be obtained from a licensed distributor. This form will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) wilJ 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 able to determine your qualifications 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. Your name and and your organization's 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 issues your permit. When the Board issues your permit, all of the inf.ormation that you have provided to the Board in the process of applying foryour 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 your organization's name and address which will remain public. Private data aboutyou are available onlyto the following: Board members, staff of the Board whose 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 legal order authorizes a new use or shadng of information after this Notice was given; and anyone with your consent. -6-