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Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit <br /> <br />Fee $50 <br /> <br />An exempt permit may be issued to nonprofit organizations <br />conducting lawful gambling activity on five or fewer days, and <br />awarding less than $50,000 in prizes during a calendar year. <br /> <br />Page 1 of 2 11/04 <br /> <br />For Board Use Only <br /> <br />Fee Paid <br /> <br />Check No. <br /> <br />Organization Information <br />Organization legal name <br /> <br />Street <br /> <br />Previous license or exemption number, if any <br /> <br />cit7 <br /> <br />State and zip code <br /> <br />County <br /> <br />Name of chief executive officer (CEO) <br /> First <br /> <br />Last name <br /> <br />Daytime phone number <br /> <br />Type of nonprofit organization (check one) <br /> [] Fraternal [] Religious <br /> [] Veteran ~ Other nonprofit organization <br /> Type of proof of nonprofit - attach a copy (see instructions) [] Nonprofit Articles of incorporation or Certificate 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 activity will be conducted (for raffles, list the site where the drawing will take place) <br /> <br />Address (do not use PO box) J City <br /> <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br />IZip code I County <br /> <br />Ch~'ck the' box o~"]~oxes that indicate the type of gambling activity your organization will be-conducting: <br /> <br /> [] 'Bingo ~] Raffles [] 'Paddlewheels [] *Puli-Tabs [] *Tipboards <br /> <br />*Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball <br />selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed <br />distributor, go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639.4000. <br /> <br />This form will be made available in alternative <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 Beard (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 />Your name and and your organb, ation's name <br />and address will be public information when <br />received bythe Board. AIl the other information <br />that you provide will be pdvate data about y0u <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 permit will become <br />public. If the Board-does not issue you a <br />permit, allthe information you have provided <br />in the process of applying for a permit remains <br />private, with the exception of your name and <br />your organization's name and address which <br />willremain 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 />MinnesotaAttorney 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 er 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 />-82- <br /> <br /> <br />