Agenda - Council - 05/25/1999 - Laserfiche WebLink

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I I I I I I I Minnesota Lawful Gambling Application for Exempt Permit - LG220 Organization Information !Organization name Page 1 of 2 10/98 For Board Use Only Fee Paid Check No. Initials Received / / Previous lawful gambling exemption number Street City Name of chief executive officer (CEO) of organization First name Last name State/Zip Code County Daytime phone number of CEO: ( ~ ~ ~ ) 'Z $'j--- ~' 7C~ c/, Name of teasurer of organization First name Last name 'ype of Nonprofit Organization Daytime phone number of treasurer. ( Check the box that best describes your o~'ganization: ~ Fraternal [] Religious [-'l Veteran [] Other nonprofit organization Check the box that indicates the type of proof y.our 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 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) Address (do not use PO box) City State/Zip Code County Date(s) of activ~;y (for raffles, indicate the date of the drawing) [] *Bingo [] Raffles [] *Paddlewheels []*Puli-Tabs [] *Tipboards *Equipment fOr these activities must be obtained from a licensed distribUtor. This form will be made available in alternative Your name and and your organization's name Private data about you are available only to the format (i.e. large print, Braille) upon request. The and address will be public information when following: Board members, staff of the Board received by the Board. All the other information that you provide will be private data abo~t you un~l the Board issues your permit. When the Board issues your perm[ all of the information that you have provided to the Board in the process of applying for your permit w~ll 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 orga~zation's name and address which will remain pubr~ information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your quar~cations to be involved in lawful gambling activilies 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 applicaUon. whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attomey General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and inte_m.aUonal gambling regulatory agencies; anyone pursuant to court order, other indMduals and agencies that are specifically authorized by state or federal law to have access to the informa~on; indMduals and agencies for which law or legal order authorizes a new use or sharing of information alter this Nof~e was given; and anyone ~ your consenL '