Agenda - Council - 03/09/2004 - Laserfiche WebLink

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Minnesota L ~.~a,-fl,rl Gambling LG220 App i:.:ation for Exempt Permit [Organizatio~ information Organization norm: Fee $50 Page 1 of 2 (web) 12/03 For Board Use Only Fee Paid Check No. Previous lawful gambling exemption number Street -¢ /City State/Zip Code / County Name of chief exe. c~ld../ek)fficer (CEO) '..,/ First -~an ~, Name of trea'.t'r,:] First nanlo Last name Last name Trc rN r/ Type of No~lpro'iit Organization Daytime phone number of CEO '7 S -- L5 IL,, Daytime phone number of treasurer: Check the box ti~at [:,est describes your organization: [] F:atemil [] Religious E~] v~¢t~l'a~ [] Other nonprofit organization Check the box Ihat indicates the type of proof your organization attached to this application: [] IRS h:ter indicating income tax exempt status [] (;erhfiCate o.¢ Good Standing from the Minnesota Secretary of State's Office [] /\ ch:.}ii:e:r :;bowing you are an affiliate of a parent nonprofit organization [] lhoof previously submitted and on file with the Gambling Control Board Gambling Premises Information Name of Address (do not u:( P(box)~ City Date(s) of aoivity ~:~r r a~fles, indicate t%e dar-b-of the drawing) prerm:~e:~ v;. ~:' fjambling activity will be conducted (for raffles, list the site where the drawing will take place) I State/ZipCode I County Check tile b'dx or boxe"s hat indicate the type of gambling activity your organization will be conducting: E~'''¢Bing° ~:'I' F"~i'?J'}s (cash prizes may not exceed $12,000) [] *Paddlewheels [] *Puli-Tabs ~Tipboards *Gambling equilm-,e~t I:or pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo bail selection dr~vi,;~) rmmt be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, g~-~ t,) vc~,,.;.gcb.state.mn.us and click on List of Licensed Distributors. Or call 6~1-639..4000. This form will be: nladn 2w~iiable in alternative format (i.e. largo pdt,t, ¢3~aille) upon request. The information r~;qtl~'X'_'d on this form (and any attachment:;) will be used by tho Gambling Control Board (~3omd) to determine your qualifications to [)u ~nvo~.zed n lawful gambling activities in Minne,;c,h~ Yf}!i have the right to refuse to supply tt~c m.ormation requested; however, if yr)u ,ef,m~: to sul;ply this information, th~:. P.o ~rd [1t2y not be able to determine yo[u qu;il:¢ication% mid. as a consequellce, ¢n;}y le~[lS(~ [0 ~SSU~ you a permit, if yo~ ;uplly hu dfformation requested, ~he uomd will b~ ~ble to process your application '(our 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 (he Board whose work assignment requires that they have access to the information; the Minnesota Depadment 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 authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.