Agenda - Council - 02/12/2002 - Laserfiche WebLink

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-54- Minnesota Lawful Gambling LG220 - Application for Exempt Permit Organiz ,afion Information Organization name isanti County Chapter Minnesota Deer Hunters Association c~ Cambridge Name of chief executive officer (CEO) First name John Last name Srlandson Page 1 of 2 8/00 "For Board Use OnJy - - Fee - $25 ~.~ Check No. Previous lawful gambling exemption number '1 S~ateTZip Code County f MN 55008 Isanti Daytime phone number of CEO 763-689-4992 Name of treasurer Daytime phone number of First name Last name treasurer. 76 :~- /, ~ ¢ - ¢ ~ I Joleen Kreisel ~-~ 763-444-9822 Type of Nonprofit Organization Check the box that best describes your organization: [] Fraternal [] Religious [] Veteran jX'-j 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 affil~.te of a parent nonprofit organization [] Proof previously submiL'ted and on file with the Gambling Control Board Gamblin~l Premises Information Name of premises where gam~!ing ..aC¢'A,4b/w~ be conducted (for reC..es, I'~t ~he s'~e where [he drawing wll! ~ke p/age} Game Fair Address_trio not use~gO box) State/Zfp Code County Date(s) of activity (for raffles, indicate the date of the drawing) August 18, 2002 Check the box or boxes that indicate the ['ype of gambling acdcty y~ur organization will be conducting: [] *Bingo [] Raffles [] *PaddJewheels []"Puli-Tabs, [] "Tipboards 'Equlcment far these ~c~ mum be obta~.ed ,,'rom a ~.~..~.~ dis~ibu~r. This form will be made available in altemadve format (i.e. fargo print, 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 iswfu! gambling activities in Minnesota. You have the right to refuse to supplythe information requested; however, If you refuse to supply this information, the Board may not be able to de, ermine your qual;'ficat~ns and, as a consequence; may refuse ~ isrc, Je-you a permit, if you supply the information requested, the Board will be able to process your applbatbn. Your name and and your organization's name and address wJl be public bformatbn when received by the Board. All the other information that you provide w~ be private da~ about you until the Bo~a'd issues your permit. When the Board issues your permit, all of the informat~n that you have provided [o the Board in the process of applying, for your permit will become public. If the Board does not issue you a permit, ali the Information you have provfded in the' process of applying for a permit remains priv~e, with the exception of your na~e and your organizatbn's rtame and address which will remain public. Private data about you are available only to ~he folicwing; 8oard members, 'staff of th~ Board whose work assignment requires that they have access to ~e infermatbn; the Minnesota Department of Pubic Safety;, the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Aud itor, national and [ntemalJanal gambling regulatory agencies; anyone pursuant to court order;, other individuals and agencies that are specificat~ authorized by s~ate or federal law to have access to the information; indMduals and agencies for which- law or lagaJ order' authorizes a new use or sharing 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 I