Agenda - Council - 07/26/2005 - Laserfiche WebLink

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REO'D J U L 1 9 2005 Minnesota Lawful Gambling LG220 Application for Exempt Permit Fee $50 An exempt permil may be issued to nonprofit organizations coaducting/awful gambling activity on five or fewer days, and awarding less than S50.000 in prizes during a calendar year. Page I of 2 11/04 For Board Use Only Fee Paid Check No. Organization Information Or!F;nmlZ~tlon legal name Name o~ chief execulive officer (CEO) Fimt ~lalT/e Last name Typ~ of nonprofit organization (check one) ~ Fraternal ~ Religious ~ Veteran ~ Other nonprofit organization Typ,~ ,)f proof of nonprofit - ~ttach a copy (see instructions) Previous license or exemption number, if any ?Daytime phone number Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office Imernal Revenue Service Affiliate of parent nonprofit organization (ct)after) A kJr')~s hie not dso PO box) -- Zip code Dab:(:,) ,)[ activity flor raffles, indicate the date of the drawing) Gambling Premises Information Name ~1 premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Check Ilar; box or boxes that indicate the type of gambling activity your organization will be conducting: [~'BH,qo [] Raffles [] 'Paddlewheels [] 'Puli-Tabs [] *Tipboards '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 Distributors. Or call 651-639-4000. f'his form ,.viii be made available ill alternative rorrmd d.c. Mroe print. Braille) upon reques[. 7 hr) inform;dion requested on this form (and ~ly ;~t~ hm~rlls)will be used by Ille Gambling r}ontru[ B~,ard fBoard) to determine your 'lualifir:alinn:-. to be inw)l,/ed ia lawful gambling ~ctivitie~; in Minnesola. You have the ri[iht to ~rdu:}~ t~* mq)ply the information requested; l~n,t.,ev~¢r if yell refuse to supply this i~t[~l'lr~;lti(¢F~ {Jl[~ Board m;]y not be able to [,erl!ilt Ii you supply Ihe information rr~rUie:;tr:d. [hn ~o~lrd will be able to process 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 Board 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. If the Board does not issue you a permit, all the information you have provided 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 assignment requires that they have access to the information; the Minnesota Department of Public Safety; the MinnesotaAttorney General; the Minnesota Commissioners of Administration. Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatow agencies; anyone pursuant to court order; other individuals and agencies that are specifically 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.