Agenda - Council - 11/26/2002 - Laserfiche WebLink

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7 Minnesota Lawful Gambling Pa:e ~ o~2- 3~o~ Application for ExemPt Permit Fee - $25 Organization,, ..._ Info.arian ch~ ~o. Organ~a~on n~e Previou~ la~ul gambling e~mp~on number Street C~ S~ip Code ~un~ Name of o~ief e~au~e o~er Fi~ name Las~ name Da~e phone numb~.ef CEO N~me of ~asurer Oa~me phone number of Fi~ name La~ name ~asuren Type of Nonprofit Organlzaaon ~ F~te~nal ~ Retlg[~us . ~ Ve~n ~O~er nonpm¢~ organ~on Ch~k ~e box that indfcates the ~pe of proof your e~anba~on a~ch~ [o tkfs applfcadon: ~ IRS leEer indicaang income t~ exempt status ~ Co.cate of Good S~nd~g Eom Be MinnesO~ Secmta~ of Sb[e's O~ce ~ A cha~er sho~ng you a~ ~ a~ of a parent nenpro~ o~ank~on ~ Proof pre~ously subm~ed and on file wi~ ~e Gambling Canal Board Gambling Premises l~formation Name of pre~l~es whe~ gambl~g a~ win be ~ndu~ed (~r m~, 11~[ Be s~e w~re ~e d~in¢ w~l take place) ' Add~ (do not use. PO box) C~ S~Jp Code Cou~ D~e(s~ of a~ (for mae;, IndUe ~; dar; of~e drawing) ~ Check ~e box or bo~hat indite ~a ~e of ga~bling a~ ~ur a~batlon w~l be ~ndu~ng; ~'Bingo ~Ra~(~shp~esmwnotex~$12,000) ~'Padd]~hee~s ~*Pu~TaSs ~pboa~s · Equipment ~r ~ese a~es mu~ be obeyed ~m a ~censed diSPuter. This form will be made available in Your name and and your organization's the following: Board member~,stalfofthe alternative format. O.e. large pdnk Bra~[e) upon request. The information requested on this form (and any attachments) will be used'by the Gambling Control Board (Board) to determine ;your qua[ifica~ons to be Involved in lawful gambling activities in Minnesota, You have the dghtto refuse to supply the informatian 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 ie4ue you a permit, Ifyou supply the information requested, the Board will be able to process your application, name and address wli] be pubFc information when received by the Board, All the other information that you provide will be private data about you u n~l the 8oard L~ues your permit. When the Board issues your permit, ail oft,he information that you have provided to the 8card in the process of applying for your permEwlil become publi~. If the @card does not Issue you a perm[t, all the information you have provided in the process of applying for a permit remains private, with the exception of your name and your organ~ation's name and address which will remain public. Private data aboutyou are evadable only to Board whose work assignment requires that ti3eY 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 Legimlive Auditor, na'~onal and intem~onal gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies .that are spec;Trolly authorized by state or federal law to have access to the information; indMduals and agencies for which law or legal order auth orlzes a new usa or shanng of information after this Notice was given; and anyone with your consent. I I I I I I, I I I I I I I I I I I -16-