Agenda - Council - 07/10/2001 - Laserfiche WebLink

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I Minnesota Lawful Garnblinc Page 1 of 2 ,,,,,,,,~..~.,~ ~uvv,~, ~c~,,,~.,,~,,.~t 'For Board Use Only LG220 - Application for Exempt Permit Fee - $25 Organization Information Check Nc. Organization name ~s lawful g~bling exemption number Street " City State/Zip Code Co'un~ Name of chief executive o~cer (CEO) Da~imep~one n~ber of CEO First name Last name - Ud~[q Name of treasurer . Da~ime phone n~mber First name ' Last name treasurer: ~ ~.; Type of Nonprofit Organization Check the box that best describes your organ.~ation: ~ Fraternal ~ Religious ~ Veteran ~'Other nonprofit organ~ation Check the box that indicates the type of proof your organBation a~ached to this application: ~ IRS letter indicating income tax exempt status - ~ Cedificate of Good Standing from the Minnesota Secreta~'of State's O~ce ~ A chaAer showing you are an affiliate of a parent nonprofit organbation ~ Proof previously submiBed and on file with the Gambling Control Board Gamblin9 Premises Information Name of premises where gambling activi~ will be conducted (for raffles, list the sffe where the drawing will take place) j ~' 3 E,~'TC-~'~ ~ ,~ ~ e N'.r ~ ~'~ .__ Address (do not use PO box) City Stat~ip Code County. Date(s) of activity (for ra~es, indicate the date of the drawing) Check the box or boxes that indicate the ~pe of gambling activiW your organbation will be conducting: *Equipment for these a~ivities must be obtained from a licensed distribQter. I I I I I I ! 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 dght to refuse to supply the information requested; however, if you refuse to supplythis information, the Board may not be able to determine your qualifications and, as a conseqbence, may refuse to issue you a permit. If you supply the information requested, the Board will' be able to process your application. -78- 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, 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 authorb, es a new use or shadng of information after this Notice was given; and anyone with your consent.