Agenda - Council - 02/14/2006 - Laserfiche WebLink

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Minnesota Lawful Gambling Page I of 2 11/04 LG220 Application for Exempt Permit Fee $50 An exempt permit may be issued to nonprofit organizations For Board Use Only Fee Paid _ Check No. conducting lawful gambling activity on five or fewer days, and awarding less than $50,000 in prizes during e calendar year. Organization Information Organization legal name Sb'eet Previous license or exemption number, if any o_ 3 5-o -oo S~te and zip code ~ Coun~ Name of chief ex¢cuave o~cer (C~O) orst name Last name Dacme phone number Ty~ Of nonprofi~ o~an~atbn (check one) ~ Fmtem~ ~¢ Relig~0us ~ Veteran ~ Other,nonprofit o~anbation Ty~ of proof of nonprofit - aEach a copy' {see instructions) ~ Nonprofit Adidas of ln~o~tio~ or Cedifi~te of G~d S~nding - Minnesota Secreta~ of State's O~ce ~ Internal Revenue Se~ice · ~ ~liate of parent nonprofit o~anizadon (charier) Gambling Premises Information Name of premises where gambling activity will be conducted (for rafites, list the site where the drawing will take place) Address (do not use PO box) City/./ Zip code County Bate(s) of activity (for reffie$, indicate the date of the drawing) Check the box or boxes that indicate the type of gambling activity your organization will be conducting: J'"-l'Bingo [] Patties [] 'Paddlewheets [] 'Pull-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 distributo~rt~g? ? www.gob.state.mn.ue and click on List of Licerised Distributors. Or call 6~1-63g-4000. This form will be made available in alternative format (i.e. large phnt* Braille)upon requesL The information requested on this form (and any at~3chments) will be used by the Gambling Control Board (Board) to determine your qualitica~ons to be involved in iswfui gambling activities in Minnesota. You have the dght to refuse to supply [he thforrnation requested; however, if you refuse to supply this information, the Board may nol be able to deten'nine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Beard will be able to process your application. Your name and and your organization's name and address will be public informalJon when received by the Board. All the other thformalton that you provide witi be pm, ate data about you until the Board issues your permiL When the Board issues your permiL all of the informal~on that you have provided to the Board in the process of applying for your permit wilt become public. If the Board does not issue you a permit, all Be information you have provided in the process of applying for a permit remains private, wilh the exception of your name and your organization's name and address which will remain public. Pdvate 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 MinnesotaAttomey General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, naltonal and international gambling regulatory agendas; anyone pursuant to court order, other individuals and agencies that are specifically authorized by slate or federal law to have access to the information; individuals and agencies for which [aw ur legal order authorizes a new use or shating of information after this Notice was given; and anyone with your sonsenL -134-