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Minnesota Lawful Gambling ~ <br />LC220 Application for i:ExemPt permit <br /> <br />Fee $50 <br /> <br />An exempt permit may be issuerd tO nonprOfit organizations <br />conducting lawful gambit,rig aotivity Onr five or fewer days, and <br />awarding less than $50,000 in jar ze~-db¢ing a calendar year. <br /> <br /> Organization Information <br /> <br />rorga]~, ation legal name <br /> <br /> Street <br /> <br /> Name of chief executive officer (CEO) <br /> First name <br /> <br />Last name <br /> <br />Page 1 of 2 11104 <br /> <br />For Board Use Only <br /> <br />Fee Paid <br /> <br />Check No. <br /> <br />Previous license or exemption number, if any <br /> <br />IState and zip code I .4 County <br /> <br /> IDaytime phone number <br /> <br />Type of nonprofit organization (check one) <br /> [] Fraternal [] Religious <br /> [] Veteran -,E~ Other nonprofit organization <br /> Type of proof of nonprofit - attach a copY (See~ instructions) <br /> [] Nonprofit Articles of Incorporation orCertificate of Good Standing - Minnesota Secretary of State's Office <br /> [] Internal Revenue Service <br /> [] Affiliate of parent nonprofit organization (charter) <br /> <br />Gambling Premises InformatiOn <br />Name of premises where gambling activi~ will be conducted (for raffles, list the site where the drawing will take place) <br /> <br />Address~do not use PO box, ~[ C,~ Zip code 3un~ <br />Da~e(s) of a~v't~jror ra~es, indicate the d~te ~(the <br /> <br />Check the hat indicate the Wee of gambl!ng activi~ your organization will be conducting: <br /> <br /> *Bingo <br /> <br />*Gambling equipment for pull-~b~, tipboards, Paddleebeeis, and bingo (bingo paper, hard cards, and bingo ball <br />selection device) must be ob~ined from a distributor licensed by the Gambling Control Board. To find a licensed <br />distributor, go to ~.gcb.s~te.mn.us and Cli~k o~ List of Licensed Distributors. Or call 651-639~000. <br /> <br />This form will be made available in aitemative <br />format (i.e. large print, Braille) upon request. <br />The information requested on this form (and <br />any attachments) will be used by the Gambling <br />Control Board (Board) to determine your <br />qualifications to be involved in lawful gambling <br />activities in Minnesota. You have the right to <br />refuse to supply the information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able to <br />determine your qualifications and, as a <br />consequence, may refuse to issue you a <br />permit. If you supply the information <br />requested, the Board will be able to process <br />your application. <br /> <br />Yoi~r name and;and your'organization's name <br />and addre,~s will be public information when <br />reCeived by the Board. ,~1! the other information <br />that you provid~ will be!private data about you <br />until the Board iss~jes your permit. When the <br />Boi~rd issues y~ur'perrnit; all of the information <br />that you have pmvidedto the Board in the <br />process of applying for your permitwill become <br />pablic. If the 8o.ard does not issue you a <br />pem~it, all the information you have provided <br />inthe process of appl'ying fora permit remains <br />private, With the exception of your name and <br />y0ur organization's name and address which <br />wil[remain public. <br />Private data about you are available only to <br /> <br />the following: Board members, staff of the <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, nationat 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 shadng of information <br />after this Notice was given: and anyone with <br />your consent. <br /> <br /> <br />