Agenda - Council - 02/24/2004 - Laserfiche WebLink

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Minnesota Lawf. u/ Gambling LG220 Appli aflon for Exempt Permit -Organization Irtfbrmation, Organization name' ~ Isanti County Chapter'' Minnesota Dee~ Hunters Association Street City 205 1st Ave ..~ Cambridge Page 1 of 2 06/03 FOr Board Use Only Fee $50 Fee Paid Check No. Previous lawful gambling exemption number IStatelzip code ~ 55008 County Isanti Name of chief executl~/e officer (CEO) First name ' ' Last name John Erlandson Name of treasurer First name Last name 5oleen Kriesel Type of Nonp[~t Or, r ganization Check the item that ~Dest describes your organization: _ Fraternal Religious Daytim~e phone number of CEO Include area code Daytime phone number of treasurer. Include area code Veteranr~ X Other nonprof'~ organization Check the item that~indicates the type of proof your organization attached to thiS application: IRS let{er indicating income tax exempt status ,. CerUfic~e of Good Standing from the Minnesota Secretary of State's Office A charter showing you are an affiliate of a parent nonprofit organization ~ Proof p~viously submitted and on file with the Gambling Control Board Gambling Pre seSlnformation &, Name of premises where gambling activity will be conduct~'~l (for raffles, list the site where the drawing will take place) Armstrong Ranch - Game Fair Address(donotusePO box) J Cb 8404 161st Ave NWI Ramsey Date(s)ofactivi~(~r~ffies, JndicatethedateofthedrawiDg) StatCzipcode ] Coun~ MN 55303 Anoka August 15, 2004 Check t6e itemiS) r . that Indicate the type of gambl ng activity your organization will be conducting: *Bingo _y_ Raffles (cash' pdzes may not exceed $12,000) *Paddlewheels *PUll-tabs *Tipboards *Equipment for these eCtivrdes must be obtained from a licensed distributor. , ~,, ~ } This form will be made'available in name and address will be public Board whose work assignment requires information when received by the Board. that they have access to the information; altemaUve format (i.e. ;lat~ge pdnt, Braille) upon request. The inf0rri~ation requested on this form (and any at~r' chrnents) will be used by the Gambling C .0ntro[ Board (Board) b3 determine your qualifications to be Involved Jn lawful gar~bllng activities in Minnesota. You have lfl~ dghtto refuse to supply the information'{e~;lUeSted; however, if you refuse to supply t~ls Inf0rm. etlon, the Board may not be able t0~det~rmine your quallfica~ons and, as a c~nseq~ence, may refuse to issue you a per~lt. [f you supply the information reque~te~l, the!Board will be able to process your ajppllcation, Your name and and yOU¢orga~zation's All the other information that you provide will be private data about you until the Board issues your permit When Ifle 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 remai6s private, with the exception of your name and your organization's name and address which will remain public. Pdvate data about you are available only to the following: Board members, staffofthe the Minnesota Deparl~nent of Public Safety; the Minnesota Attomey 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 sharing of information after this Notice was given; and anyone with your consent.