Agenda - Council - 01/24/2006 - 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 tess than $50,000 in prizes dudng a calendar year. Organization Information Organization legal name Minnesota Deer H~nters Association Isa.uti County Chapter Street City ~ P~;/3o~ '-/'-/~, Cambridge ',tame of chief executive officer (CEO) ?a ~-r- ~op.. ~ t~ ~ 7-- First name Last name J'ohn Erlandson Page 1 of 2 11/04 JFor Board Use Only Fee Paid Check No,__ Previous license or exemption number, if any State and zip cdde County MN 55008 Daytime phone number 763-689-4992 Type of nonprofit organization (check one) [] Fraternal [] Religious [] Veteran [] Other nonprofit organization 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 [] Internal Revenue Service [] Affiliate 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) Armstrong Ranch/Gamefair Address (do not use PO box) City 8404 161't Ave NW -A~r.;k.~ /~ ~q-,~ ~& Date(s) of activity (for raffles, indicate the date of the drawing) August 20, 2006 Zip code 55303 Anoka Check the box or boxes that indicate the type of gambling activity your organization will be conducting: [] 'Bingo [] Raffles [] 'Paddlewheels [] 'Puli-Tabs [] ~l')pboards '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 Dist.~ibutor~. Or call $51-639-4000. Thkt form will be made available in altema~ve format (i.e. large pdnt Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the dght to refuse :o supply the ~nformation 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 name and address will be public information when received by the Boan:l. A~I the other information that you provide will be private data about you until the Beard issues your permit. When the Board issues your permit, all of bhe 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 cf applying for a permit remains pdvate, with the exception cf your name and your organization"s name and address which will remain public. Private data about you are avat[able only to the following: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department cf Public Safety; the MinnesotaAttomey General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatc~J agencies; anyone pursuantte o~urt order;, other individuals and agenc/es that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authonzes a new use or shadng of information after this Notice was given; and anyone with -44-