Agenda - Council - 05/11/2004 - Laserfiche WebLink

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Minnesota Lawful-Gambling LG220 Application' for Exempt Permit Fee $50 Page 1 of 2 6/03 ' For Board Use Only IFee Paid_ I Check No. Organization Information Organization name Street / ~ City Previous lawful gambling exemption number tState/Zip Code Cou, nty Name of chief executive officer (CEO) First name Last name N~me of treasurer First,rj.g.me . Last name Type of Nonprofit Organization Oaytim~ phone number of CEO Daytime phone number of treasurer: _ . , r Check [he box that best describes your organization: E~ Fraternal [] Religious [] Veteran [] Other nonprofit organization Check the box that indicates the type of proof your organization attached to [his application: E~ IRs Fetter indicatihg 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 Address (do not use PO box) City Oata(s~of activity (for raffles, indicate tile date of the drawingi ~_/ Name ~t-oremises where g~bling activity will be conducted (for raffles, list the site where [he drawing wilt take place) StateiZipCode ChecX the box or boxes that indicate the type of gambling activity your organization will be conducting: [] "Bingo [] Raffles (cash prizes may not exceed $12,000) [] *Paddlewheels []*Puli-Tabs · .~,~ dr, mc,nj' rr~r these activities must be obtained from a licensed distributor. [] *Tipboards This t~orm will be made available in aiternative format (i.e. large print, Braille) uoort request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be ,;n'¢:,q,'ed /n lawful gambling activities in Minnesota. ";ou have the right to refl. lse to supply ~.he information requested; however, if,/ou re,se ~o 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 s'upply the information requested, the Board will be able .'.o procgss your application. Your 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 privat, e 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 ,,viii become public. If the Board does not issue you a permit, all the information you have provided in the process of applying for a pen-nit remains private, with the exception of your name and your organization's name and address which will rernain public. Private data about you are available only Io the following: Board members, staff of the Board whose work assignment requires that they have access to (he information; Ihe Minnesota Department 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 ,~ederal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or si~aring of information after this Notice was given; and anyone with your consent.