Agenda - Council - 07/25/2006 - Laserfiche WebLink

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L-G220 Application for Exempt Permit Fee $50 For Board Use Only Fee Paid An exempt permit may be issued to a nonprofit organization conducting lawful gambling activity on five or fewer days, and Check No.___ awarding less than $50,000 in prizes durings a calendar year. Organization Information Organization name 11 e. c.J~.J-J Previous lawful gambling exemption number AIIO ke, C':;;"'^~1y 1=::> (' 0( ...I/2r X - 0 "'?;?9cJ Street / ( ~~ 4/v~ Cc /C,A ~clJ State/Zip Code I cAnty k if/ .,::I~ ':.J .:;;,:) 1"1 ~ f".rYj] II ::J $" Name of chief executive officer (CEO) Daytime phone number F~ ~;~ last name . SZ t2'?A ~J-r4;......, '/63 ").r >- ..., I , 0 Type of Nonprofit Organization Type of nonprofit organization (check one) o Fraternal c 0 Religious o Veteran ~ Other nonprofit organization . Type of proof of nonprofit status - attach a copy (see instructions) 0 Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office 0 Intemai Revenue Service 0 Affiliate of parent nonprofit organization (charter) ~ Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information > Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) ~&,htf) Fc,s"... Address (do not use PO box) City . Zip Code County 81.(0 'I f61J1- A~< i(Cfhtf(' >- SSJQ] A J'1 :; ,L:. $ Date(s) of a87 ;~rai~ZdjCate the date of the drawing) Check the box or boxes that indicate the type of gambling activity your organization will be conducting: o -Bingo ~ Raffles o -Paddlewheels o -Pull-Tabs o -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. Minnesota Lawful Gambling ./ This form will be made available in alternative format (Le. large print, 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 involvedin lawful gambling activities in Minnesota. YoLl have the right to refuse to supply the 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 Board will be able to process your application. C 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 -122- HECrD JUL 07 2005 Page 1 of 2 2/06 . . 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 Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that !\Ire specifically authorizEld 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. .