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Minnesota'La wful Gambling
<br />LG220 Application for Exempt Permit
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<br />Fee $50
<br />
<br />Organization Information
<br />
<br />REI 'B J UN 0 6 2005
<br /> Page 1 ct 2 (web) 12./03
<br /> · :or Board Use Only
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<br />Fee Paid
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<br />Check No.
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<br />Orflaniz;~lion name
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<br />Strr;el
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<br />~__~'3/-t $, l~e_~r~ ..~-~'ree~'l
<br />Name of chief execuBve ~ficer (CEO)
<br /> Firsl name
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<br />Name of treasurer First name
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<br /> Last name
<br />1V O, gr kt, t g b i'x-
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<br />Last name
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<br />Type of Nonprofit Organization
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<br />Previous lawful gambling exemption number
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<br />State/Zip Code I County
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<br /> Daytime phone number of CEO
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<br /> Da~ime phone number of
<br /> ~easurer:
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<br />Clleck Ihs box Ihal best describes your organization: .,
<br /> [] Fraternal [] Religious
<br /> L~ Veteran [] Other nonprofit organization
<br />Check Ihs box that indicates the type of proof your organization attached to this application:
<br /> [] IRS letter indicating income tax exempt status
<br /> certificate of Good Standing from the Minnesota Secretary of State's Office
<br /> [] A chafer showing you are an affiliate of a parent nonprofit organization
<br /> [] Proof previously submitted and on file with the Gambling Control Board
<br />Gambling Premises Information -. .....
<br />Name ol' premises where gambling ac(ivlty will be conducted (for raflles, list the site where the drawing'will take pi~oe) '
<br />
<br />[] *Bingo [] Raffles (cash pdzes may not ex,ed.' $12,000),..,. : . [] 'Paddlewheels . [] 'Puli-Tabs: . .r~ -'lipboards
<br />'Gambling equipment for pull-tabs, flpb°arde, Paddlewheels, ~nd bingo (bingo paper, hard CardS: ~nd bingo ball
<br />selection device) must be obi;alned from a distributor iicensed by f.h.e Gambling Oon~rol Board. To find a licensed
<br />distributor, go to www.gcb.state,mn.us and clio[ on List of Llcensed Dlstdbutor~. Or call 651 439-4000. ~...
<br />
<br />-l'hts form will be made available in alternative
<br />'/orma! (i.e. large print, Braille) upon request.
<br />"~e intormation requested on this form (and
<br />any allad]ments) will be used by the Gambling
<br />Conlrol Board (Board) to delermine your
<br />qualilications to be involved in lawful gambling
<br />activities in Minnesota· You have the fight to
<br />refuse to supply the information requested;
<br />however, if you refuse Io supply this
<br />in~'ermation, the Board may not be able.to
<br />
<br />Your name and and your organiza~n's name
<br />and address wilt be public information when
<br />received bythe Board. A~I theothertnformation
<br />tha! you prov'~le w,l be private data about you
<br />until the Board issues your permit. When the
<br />Board issues your permit, all of the information
<br />that you have provided to the Board in the
<br />process of applying for your perm'~.~ll become
<br />· public. If the Board does not Issue you a
<br />pem~ll~ all the I~ormation you have provided
<br />
<br />the following: Board members, stall of the
<br />Board whose work assignment requires that
<br />they have access to the In~ormation; 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 />regulatorYagencies; anyone pursuanttocourt , '":
<br />order, other individuals and agendas that are .-~-.i!..:: ': '
<br />
<br /> determine your qualifications and, as a intheprocessofapPlyingforapermif, remains specificallyauthofizedbystateorfederal aW::..` !i.~;?'~'~.'
<br /> consequence, may refuse to issue you a private, withtheexceptionofyournameand to have aocess to the inforrnation; individdals ',* .'~-?.?;:· .
<br /> permit. If you supply lhe information yourorganization'snameandaddresswhic-h ;and agencies for.which law or legal order.-..~-.7_::..':"i~ ,
<br /> requesled, the Board will be able lb process .' will remain publiC: ~.~.ii'.;~;!'.:.':~!~ .' · '.' ~'authorizes a neWuseorshadng ofinformation: !:.?..."~i"¢' '
<br /> your application. . Private data aboutyo~'~re 'available only to a~.er this Notice was given; and anyone with '~..~_.'i-'. '
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