Agenda - Council - 05/10/2005 - Laserfiche WebLink

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Minnesota Lawful Gambling LG220 Application for Exempt Permit Fee $50 An exempt permit may be issued to nonprofit organizations conducting lawful gambling activity on five or fewer days, and awarding less than $50,000 in prizes during a calendar year, Organization Information Organization J~lgal name Street t'~- City Name of chief executive officer (CEO) First name Last name , .. Type of nonprofit organization (check one) ~ Fraternal ~ ~eligious ~ Veteran ~ther nonprofit organization Type of proof of nonprofit - affach a copy (see instructions) Page 1 of 2 11104 For Board Use Only Fee Paid Check No. Previous license or exemption number, if any State and zip code County Daytime phone number [] Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office [] Internal Revenue Service Ei~4~ffiliate of parent nonprofit organization (charter) Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) 'Add,ess (do not'use PO b~ox) I City I Zip code County I e oda Date(s) Of activity (for raffles, indicate th te f the draWing) / Check the box or boxes that indicate the type of gambling activity your organization will be conducting:, J--"]*Bingo [-~]'"'"'Raffles [] 'Paddlewheels [] 'Pull-Tabs [] *'Rpboards *Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to www. gcb.state,mn.us and click on List of Licensed Distflbutors. Or call This form will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on t~is form (and any attachments) wilt be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the ~ight 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 n amc 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. Wl~en the Board issues your permit, all of the information that you have provided to the Board in the process of applying for you~: permitwill become public, If the Board does not issue you a permit, all the information you have pro.vided 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: Board members, staff of the Board whose work ass!gnment requires that they have access to the information; the Minnesota Depactment of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agendes; anyone pursuant to court order;, other individuals and agencies that are specJficatiy authorized by s~ate 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.