Agenda - Council - 06/11/2002 - Laserfiche WebLink

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Minnesota Lawful Gambling LG220 - Application for Exempt Permit Organization Information Organization name Page 1 of 2 3/01 For Board use Only Fee- $25 Check No. Previous tawful gar~bling exemption number Street Name of chief executive 'e~rfi'cer (CEO) First name Nama o? tr~surer First name city Last name Last name State/Zip Code Count7 Daytime phone number of CEO Daytime phone number of treasurer: Type of Nonprofit 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 I~r'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 Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Date(s) of activ~ (for ra~es, indicate ~e date of Be d~awin~ Check the box or boxes that indicate the type cji gambling activity, your organization will be conducting: ]~ *Bingo [] Raffles (cash prizes may not exceed $12,000) [] *Paddlewheels [] 'PuIFTabs ~*Tipboards '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 the following: Board members, staffofthe I ! I I I I I I I I I I -98- alternative format (i.e. large pn'nt, 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 dghtto refuse to supplythe 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. name and address will be public information when received by the Board. All the other information that you provide will be pdvate 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 8oard does not issue you a permit, all the information you have provided in the process of applying for a permit remains pdvate, 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 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. I I I I I