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

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Minnesota Lawful Gambling LG220 Application for Exempt Permit Organization Information Organization name (~y ....fc/l~..5 L Street (S-3 ,$ Page 1 of 2 (web) 12/03 Fee $50 Fee Paid . Check No. Previous lawful gambling exemption number Name of treasurer First name Last name K -... '") t , c/l.,\ Type of Nonprofit Organization Check the box that best describes your organization: o Fraternal 0 Religious o Veteran t2?[ Other nonprofit organization Ch€ck the box that indicates th~ type of proof your organization attached to this application: o IRS letter indicating income tax exempt status o Certificate of Good Standing from the Minnesota Secretary of State's Office o A charter showing you are an affiliate of a parent nonprofit organization o Proof previously submitted and on file with the Gambling Control Board Gamblin Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) f,;-( h1 ", (/..v, r C (,., h ~ rIC- Address (do not use PO box) StatelZipCode County 17 5' (1..(7 I.{ VI oJ!.. '!i-4..' Date( s) of activity (for raffles, indicat~ the date of the 'r}~' . 4Lt '". Check the box r boxes that indicate the type of gambling activity your organization will be conducting: o "Bingo . ~ Raffles (cash prizes may not exceed $12,000) 0 "Paddlewheels 0 "Pull-Tabs 0 "1ipboards "Gambling equipment for pull-tabs, tlpboards, paddlewheels, and bingo (bingo paper, hard cardll, 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. Last name StatelZip Code !>AN 5'5"' (J~ County ftnOJ< Daytime phone number of CEO ')03 )...2.( '-I /2- Daytime phone number of treasurer. 6J7- ?;-6)h IgV7 . hi J1 '))' '" 1,-1'1.*,1} This form will be made available in alternative format (Le. large print, Braille) upon request The information requesled 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 right to refuse to supply the information requested; however, if you refuse to supply this information, the Board niay not be able to <ietermine your qualifications and, as a consequence, may refuse 10 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 re~ived by the Board. All the other information that you provide will be private data about you until the Board issues your permiL When the Board issues your permit, all of the information that you have provided to the Board in the process of ~pplying for your permit will become public. If the Board does not issue you a permit, all the information you have provided in the p'rocess cf 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 -126- 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 MinnesolaAttomey 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 are . specifically authorized by state or federal law .', to have access to th'l<fhformation; individuals:" and agencies for Which law CltJegal order authorizes a new uSaor sharing of information after this Notice was given; and anyone with yourconsenL .