Agenda - Council - 07/27/2004 - Laserfiche WebLink

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Minnesota Lawful Gambling LG220 Application for Exempt Permit Fee $50 Organization Information Page 1 of 2 (web) 6/03 For Bo~;d I.J~ 0nly Fee Paid Check No. Organization name I city Name of chief executive officer (CEO) First name Last name Name of treasurer First name Type of Nonprofit Organization Last name Previous lawful gambling exemption number State/zip code [ County Daytime phon6 number of CEO Include area code 9..,//I Daytime phone number of treasurer. Include area code Check the item that best describes your organization: __ Fraternal Religious , Veteran ~(Other nonprofit organization Check the item that indicates the type of proof your organization attached to this application: __ IRS letter indicating income tax exempt status Cedificate 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 Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Date(s) of activity (for ra~es, indicate the date of ~e drawing) County Check the item(s) that indieat~ the type of gambling activity your organization will be conducting: 'Fdingo ~Raffies (cash prizes may not exceed $12,000) ~ 'Paddlewheels *Equipment for these activities must be obtained from a licensed distributor. __'Pull-tabs *T~pboards This form will be made available in altemative 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 9ambling activities in Minnesota. You have thC right to refuse to supply the information ~equested; however, if you refuse to supply (i~is information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. ]f 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 Beard 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. ]f the Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains pdvate, 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 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 Administ~tion, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agendes; anyone pursuant to court order; other individuals and agendes that are spedfically 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.