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Minnesota Lawful Gambling <br />LG220 - Application for Exempt Permit <br /> <br />Fee- $25 <br /> <br />Organization Information <br />Organization name <br /> <br /> City <br />Street pjOd~fl <br />Name of chief executive o~ce~ (CEO) <br /> Fimt name Last name <br /> <br />Name of treasurer First n~me <br /> <br />Last name <br /> <br />Type of Nonprofit Organization <br /> <br />Previous lawful gambling exemption number <br /> <br /> Page 1 ol 2 ,~/u ~ <br /> <br />tare/Zip Code County <br /> <br /> Daytime phone number of CEO <br /> <br /> 765 , <br /> <br />Daytime phone number of <br />treasurer: <br /> <br />Check the box that best describes your organization: <br /> [] Fraternal [] Religious <br /> [] veteran [] Other nonprofit organization <br /> <br />Check the box that indicates the type of proof your organization attached to this application: <br /> [~ IRS letter indicating income tax exempt status <br /> [] Certificate of Good Standing from the Minnesota Secretary of State's Office <br /> [] A charter showing you are an affiliate of a parent nonprofit organization <br /> [] Proof previously submitted and on file with the Gambling Control Board <br /> <br />Gambling Premises Information <br /> <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br /> <br /> use [ I I County <br />Address (do not PO box) CiW ~ State~ip Code <br /> <br />Date(s) of acd~ty (for tabes, indicate the date of the drawing) <br /> <br />Check the ~h'at i~dicate the ~e of gambling actMty your organi~tion will be conducting: <br /> <br /> 're. Co a .ot $ 2,000) <br /> <br />*Equipment for these actMties must be obtained from a licens~ dis~butor. <br /> <br />This form will be made available in <br />alternative format (i.e. large print, Braille) <br />upon request. The information requested <br />on this form (and any attachments) will be <br />used by the Gambling Control Board <br />(Board) to determine your qualifications to <br />be involved in lawful gambling activities in <br />Minnesota. You have the dght to refuse to <br />supply the information requested; however, <br />if you refuse to supply this information, the <br />Board may not be able to determine your <br />qualifications and, as a consequence, may <br />refuse to issue you a permit. If you supply <br />the information requested, the Board will <br />be able to process your application. <br /> <br />Your name and and your organization's <br />name and address will be public information <br />when received by the Board. All the other <br />information that you provide will be private <br />data about you until the Board issues your <br />permit. When the Board issues your <br />permit, all of the information that you have <br />provided to the Board in the process of <br />applying for your permit will become public. <br />if the Board does not issue you a permit, <br />all the information you have provided in the <br />process of applying for a permit remains <br />private, with the exception of your name <br />and your organization's name and address <br />which will remain public. <br />Pdvate data about you are available only to <br /> <br />the following: Board members, staff of the <br />Board whose work assignment requires <br />that they have access to the information; <br />the Minnesota Department of Public Safety;, <br />the Minnesota Attorney General; the <br />Minnesota Commissioners of <br />Administration, Finance, and Revenue; the <br />Minnesota Legislative Auditor, national and <br />intemational gambling regulatory agencies; <br />anyone pursuant to court order; other <br />individuals and agencies that are <br />specifically authorized by state or federal <br />law to have access to the information; <br />individuals and agencies for which law or <br />legal order authorizes a new use or sharing <br />of information after this Notice was given; <br />and anyone with your consent. <br /> <br /> <br />