Agenda - Council - 04/23/2002 - Laserfiche WebLink

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Minnesota Lawful Gamblinc Page 1 of 2 3/01 ,,,,,,~,.,-,.,,.,..., ~...av,-~,.~.~ '...' a ,' , ,'-' ," ~ ,' ...'.w For Board Use Only LG220 - Application for Exempt Permit Fee ' $25 FeePaid Organization Information Check No. , Organization name Previous lawful gambling exemption number Street City State,Zip Code Coun~ Name of chief executive o~cer (CEO) First name Last name Da~ime phone number of CEO Name of treasurer Da~ime phone number of First name Last name treasurer: Type of Nonprofit Organization Check the box that best describes your organization: ~ Fraternal ~. Religious ~ Veteran ~Other nonprofit organization %0 ~ Q ~ 1 Check the box that indicates the type of proof your organization aEached to this application: %IRS leper indicating income tax exempt status ' e~ificate of Good Standing from the Minnesota Secreta~ of State's O~ce cha~er showing you are an affiliate of a parent nonprofit organization ~ Proof previously submi~ed and on file with the Gambling Control Board Gamblin~ Premises Information Nam~.of premises where gambling activ~ will be conducted (for ra~es, list the sit~.where the drawing will take place) Address (do not use PO box) Ci~ State~ip Code Coun~ Date(s) ~f a~iVi~ (for ra~es, indicate t~'e date of the drawing) Check the Doxies that indicate the ~pe of gambiing actbi~ your organbation will be conducting: 'Equipment for these actMties must Bo obtainod ~om a licensed dist~butor. I I I I This form will be made available in alternative format (i.e. large pdnt, 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 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. -46- 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 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 your organization's name and address which will remain public. Private data about you are available only to the following: Board members, staffofthe 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 sharing of information after this Notice was given; and anyone with your consent.