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EG'D MAY ? 2004
<br />
<br />Minnesota Lawful Gambti/Tg
<br />LG220 Application for xempt Permit
<br />
<br />Fee $50
<br />
<br />Organization hfformation
<br />
<br />Page 1 of 2 (web) 12t03
<br />'Fbr Board Use Only
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<br />' Fee Paid
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<br />~ Check No.
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<br />Organization ~mmc A ' Previous lawful gambling exemption number
<br />'Stree¢ ........ ~ ;it',- - -- Code
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<br /> Daytime phone number of CEO
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<br /> Type of Nonpr~ffJt OrganizatJo ,
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<br />Daytime phone number of
<br />treasurer: -~.~ ~ ~- ,,~ ! ~O
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<br />Check the box thai i;,}.st describes you or(¢'anization:
<br /> ~] f:r[!lerr~ai [~ Reigio~s
<br /> ~ Veb:rzm .~Oth~ r m~nprofit organization
<br />Check thr: box ihmi h~dica[es '.1~; type <.¢ proof your organization attached 1o this application:
<br /> IR.t; Imtm indicatinfi ir~come ax ~;xempt status
<br /> Certifica~:¢ of Good S(andinF from the Minnesota Secretaw of State's Office
<br /> A r:h;/l'[oJ showing '/otJ qre al ~flfiliate of a parent nonprofit organization
<br /> Prrx)[ previously submitted a:nd (,n file with the Gambling Control Board
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<br />Gambling Premises Informatio,q
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<br />Name of pren fish.'; ,,vtx}~ c. flamhlino acth/i~y vv; ¢ be :onducted (for raffles, list the site where the drawing will take place)
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<br /> Addres;; ldo r~u~ :~':~: ts'() b,)x) } {.~tv State/ZipCode County
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<br />/)ah)(:; ) o[: ;x:[Jvdv (,r)r i~ i[[f~h indim~tc the dat~ of [I,-~ drawing)
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<br />'(~{~ck Ibc box 'or !,oxn :: flint md~'ca~e ~he type ,f ,;ambling activity your organization will be conducting:
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<br /> ~ 'Bing~, ~' R;, ¢los (cash ¢,nzss ,nay x,(-,xceed S12,000) ~ 'Paddlewheels ~ *Puli-Tabs ~ *Tipboards
<br />'Gambling equipmeni for pull4abs, tipboacds, paddlowheeis, and bingo (bingo paper, hard cards, and bingo ball
<br />selection devic3) mli,4t be obtained from ;~ distributor licensed by the Gambling Control Board. To find a licensed
<br />distributor, ;lo [o wwv¢.gcb.state.mn.us a~,d ,;lick on List of Licensed Distributors. Or call 651-639-4000.
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<br />This form will he rmx k,. avai ahle in allen ~ative
<br />
<br />qualifications !obc invr)lved r ~ i;IWl't;J gall :t)li~/f~
<br />h(~w~}vr~l. ~f VI)Ii f:~lJ~;c ) :~tl!)lily thir;
<br />
<br />parred. If y~)~ ';~,piy 'lu~ mform~ti~m
<br />
<br />yom' ;ll)r)li(xllh )l~
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<br />name and and your organization's name the following: Board members, staff of the
<br />
<br />am address will be public information when
<br />c ec~ ,ivmd !)y the Board. All the other information
<br />tha~ :/ot~ :~rovide will be private data about you
<br />tu]t~ the ~}oard issues your permit. When the
<br />Bo~ r-d issues your pe~it, alt of the information
<br />fha, y{u nave provided to the Board in the
<br />~x (x es; ;-f app~yin9 for your permit will become
<br />pULr C. ~(he Board does not issue you a
<br />pe~, ,~it..~,1 the information you have provided
<br />~n tl-:~ ?occss of applying for a permit remains
<br />priv ~te, with d~e exception of your name and
<br />you xqamzation's name and address which
<br />,viii r 'm~a:n puMic.
<br />n~',iv ~tc :~ta atTout you are available only to
<br />
<br />Board whose work assignment requires that
<br />they have access to the information; the
<br />Minnesota Department of Public Safety; the
<br />Minnesota Attorney General; the Minnesota
<br />Commissioners of Administration, Finance,
<br />and Revenue; the Minnesota Legislative
<br />Auditor, national and international gambling
<br />regulatory agencies; anyone pursuant to court
<br />order; other individuals and agencies that are
<br />specifically authorized by state or federal law
<br />to have access to the information; individuals
<br />and agencies, for which law or legal order
<br />authorizes a new use or sharing of information
<br />after this Notice was given; and anyone with
<br />your consent.
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