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<br />LG220 Application for Exempt Permit Fee $50 For Board Use Only <br /> Fee Paid <br /> An exempt permit may be issued to a nonprofit organization <br /> conducting lawful gambling activity on five or fewer days, and Check No. <br /> awarding I~ss than $50,000 in prizes durings a calendar year. <br />Organization h,formation <br />Organization name- CAST" Previous lawful gambling exemption number <br />"TURN IN paAc\-.E.~ - '~'I Me-ru> C H P, ? <br />Street R:> '!;x 01\6'38 City eAG.4 ~ StatelZip Code County <br />~qq~ Stet.E"i HW'f. Mil 5S/~1 PA Kt1, A <br />Name of chief executive officer (CEO) Daytime phone number <br />FiTSAaze Last name <br /> rHOAAA.f 6$/- '-IO~- 9/ f I <br />Type of Nonprofit Organization <br />Type of nonprofit organization (check one) <br />o Fraternal o Religious <br />o Veteran r:g Other nonprofit organization <br />Type of proof of nonprofit status - attach a copy (see instructions) <br />0 Nonprofit Articles of I ncorporation or Certificate of Good Standing - Minnesota Secretary of State's Office <br />glnternal Revenue Service <br />D Affiliate of parent nOl'lprofit organization (charter) <br />o . Proof previously submitted and on file with the Gambling Control Board <br />Gambling Premises Information <br /> , <br />Name of premises where gambling activity will. be conducted (for raffles, list the site where the drawing will 18 ke place) <br /><DMAE t=14lR <br />Address (d? not use PO box) City Zip Code County <br />8'1Ot.( IbLSi Av~ NLO ~M5E Y 55 :3<:?3 ,A M() KA <br />Date(s) of activity (for raffles, indicate the date of the drawing) D It4 W } NG . 0 A.J <br />Au(o. 1(-\"3 . 'AUG. t8/- 201 Za::>~ ;4v~ . ;';;OJCi1ct:'cG <br />Check th~ box or boxes that indicate the type of gambling activity your organization will be COnducting: ,. <br />D. *8ingo I;xJ Ra ff1es o *Paddlewheels o *Pull-Tabs o *Tipboards <br />'"Gambling.equipmentfor. pull-ta'bs, tip~oards, p~ddlewh~els,.and bingo (bingo paper, hard cards, and bingo ball <br />stiiei:..i':;.i tl=~i..;~; IIi";:" ..'w": ."":~ ".::.: ~ -;'. ;"..., ~".j::+.. ::.-:.:~c:" !~.,,::.~.:: ,:~'f~. :-1~~ (""-:"..~Jin:! r:o"tr~1 Boarr.. To find a licensed i <br />distributor, go to y.JWW.gcb.state.mn.us aillhlick on List ofLic~nsed Distributors. Or call 651-639-4000. <br /> <br />~ <br /> <br />Minnesota Lawful Gambling <br /> <br />This form Will be made availa ble in alternative <br />format{i.e. large print, Braille) upon request. <br />The information requested on this form (and <br />any attachments) will be used by the Gambling <br />Control Board (Boare)to determine your <br />qualifications to be involved in lawful gambling <br />activities in Minnesota. You have the right to <br />refuse to supply the information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able to <br />determine your qualifications and, as a <br />consequence, may refuse to issue you a <br />permit. If you supply the information <br />requested, the Board will be able to process <br />yourapplication. <br /> <br />-130- <br /> <br />REC'O JUL 18 2006 <br /> <br />Page 1 of2 <br /> <br />2/06 <br /> <br />. <br /> <br />. <br /> <br />Your name and and your organization's name <br />and address will be public information when <br />received by the Board. All the other information <br />that you provide will be private data about you <br />until the Board issues your permit. When the <br />Board issues your permit, all of the information <br />that you have provided to the Board in the <br />process of applying for your permit will become <br />public. If the Board does not issue you a <br />permit, all the information you have provided <br />in the process of applying for a permitremains <br />private, with the exception of your name and <br />your organization's name and address which <br />will remain public. <br />Private data about you are available only to <br /> <br />the- following: Board members, staff of the <br />Board whose work assignment requires that <br />they have access to the information; the <br />Minnesota Department of Public Safety; the <br />Minnesota Attorney General; the Minnesota <br />Commissioners of Administration, Finance, <br />and Revenue; the Minnesota Legislative <br />Auditor, national and.intl!!rnational gambling <br />regulatory agencies; anyone pursuant to court <br />order; other individuals and agencies that are <br />specifically authorized by state or federal law <br />to have access to the'jnformation;Jndividuals <br />and agencies for which law or legal order <br />authorizes a new use orsharing of information <br />after this Notice was given; and anyone with <br />your consent. <br /> <br />. <br />