Agenda - Council - 07/28/1998 - Laserfiche WebLink

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Minnesota Lawful Gambling Application for Exempt Permit - LG220 Organization Information For Board Use Only Fee Paid Check No. Initials Received / / Organization name Previous lawful gambling exemption number Street ~-J City ' State/Zip Code County Name of chief executive officer (CEO) of organization Daytime phone number of First name Name of te~surer of organization First name Type of Nonprofit Organization Last name Last name CEO: Daytime phone number of treasurer: Check the box that best describes your organization: [] Fraternal [] Religious [] Veteran [~ther 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 p charter showing you are an affiliate of a parent nonprofit organization roof 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 Date(s) of activity (for raffles, indicate the date of the drawing) e box or boxes that indicate the type of gambling activity your organization will be conducting: County [] 'Bingo [_~affles [] *Paddlewheels []*Puli-Tabs [] *Tipboards *Equipment for these activities must be obtained from a licensed distributor. This form wil~ be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form will become public information when received by the Board, and will be used to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. Page 1 of 2 3/98 I I I I I I I I I I I