Agenda - Council - 02/28/2006 - Laserfiche WebLink

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REC FEB g I 2006 Minnesota Lawful Gambling LC220 Application for Exempt Permit Fee $50 An exempt permit may be issued to nonprofit organizations conducting lawful gambling activity on five ar fewer days. and awarding less than $50,000 in prizes during a calendar year. Organization Information Organization legal name Street Name of chief executive off~cer (CEO) First name_ , city Last name Type of nonprofit organization (c..(.~ck one) [] Fraternal ~___] Religious [] Veteran [] Othernogprofit organization Page 1 of 2 11104 For Board Usa Only Fee Paid Check No. Previous license or exemption number, if any State and zip code County ~a~ime phone n~mber e o roof of non 'refit - attach a copy (see instructions) TY~N~nprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Offic~ [] 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) Address (a(~ not use PO box) ~iVd City I Zip code Date(s) of a~Jvity (for raffies,.~te th.~ date ~f the d~wing) - Check the box or boxes that indicate the type of gambling activity your organization will be conducting: *Gambling equipment for pull-tabs, flpboards, 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 Disa'ibutors. Or call 651-639-4000. This form will be made available in alternative Your name and and your organization's name the foltowing: Beard members, staff of the format (i.e. large pdnt, Braille) upon request, The information requested on this form (and any attachment) will be used by the Gambling Control Board (Board) to determine your quaJJl~sstions to be inv~ved in lawful gambling activities in Minnesota. You have the right to refuse Jo supply t~e information 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 Beard will be able to process your applicaQon. and address will be public in~rmation when received by the Beard. AJI the other informa~cn that you provide will be pdvate data about ~u until the Board issues your permit. When the Board issues your permit, alt of the ioforma~on that you have provided to the Board in the process of app~ng f~ 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 pdvate, with the exception of your name and your organization's name and aqdress which will remain public. Private data about you are available only to Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnescta Attorney General; the Minnesota Commissioners of Administ~'ation, Finance, and Revenue; the Minnesota Legislative Auditor, national and intemattonal gambling regulatory agendas; anyone pursuant to cc~ur[ order, other individuals and agendas that are specifically authorized by state or federal law to have access to the information: individuals and agencies for which law or legal artier authorizes a new use or shanng of information alter this Notice was given; and anyone with -40-