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

Home

Minnesota Lawful Gambling LG220 Application for Exempt Permit Fee $50 Page 1 of 2 (web) 12/03 For Board Use Only Fee Paid _ Check No. Organization Information Organization name Street I City / Name of chief executive o~cer (CEO) First name Name of treasurer First name Last name Last name Type of Nonprofit Organization Previous lawful gambling exemption number State/Zip Code I County Daytime phone n~mber of CF_O Daytime phone number of treasurer: Check the box that best describes your organization: [] Fraternal [] Religious [] Veteran Blather 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 E~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 Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Address (do not/t, Jse P,.O bo~() I City State/ZipCode County Date(s) of activiW (for ra~es, indicate t~e date of the drawing) Check the box or boxes that indicate the type of gambling activi~ your organization will be conducting: *Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo bail selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to ~.gcb.state.mmus aod click oo List of Eicensed Distributors. Or ca11651-639~0~. This form will be made available in alternative format (i.e. large print, Braille) upon 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 involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to 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 supply the information requested, the Board will be able to process 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 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: Boar¢ members, staff of the Board whose work assignment requires that they have access to the' information; the 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 federal law to have access to the information; individua(s and agencies for which law or legal order authorizes a new use or shadng of information atter this Notice was given; and anyone with your consent.