Agenda - Council - 02/13/2007 - Laserfiche WebLink

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iiLUU JAN I ZUU% asofa Lawful. Gambling , 3n fnr 0^*-r A+ Cnn OtAn Page 1 of 2 11104 r.v.— %VVAA%1% -a ■ ■v■ AANa . % iI11at1, a vv . For Board Use Only An exempt permit may be issued to nonprofit organizations Fee Paid conducting lawful gambling activity on five or fewer days, and awarding less than $50,000 in prizes during a calendar year. Check No. nization Information Organ ization legal name Minnesota Deer Hunters Association Previous license or exemption number, if any Isanti County Chapter Street City State and zip code County 201- I" Ave.E Cambridge MN 55008 Name of chief executive officer (CEO) First name Last name Daytime phone number John Erlandson 763 -689 -4992 Type of nonprofit organization (check one) ❑ Fraternal ❑ Religious ❑ veteran X] Other nonprofit organization Type of proof of nonprofit - attach a copy (see instructions) ❑ Nonprofit Articles of Incorporation or Certificate of Good Standing -Minnesota Secretary of State's Office ❑ 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) Armstrong Ranch/Gamefair Address (do not use PO box) City Zip code County 8404 -161 Ave.NW 4021a NA1 S e ` 55303 Anoka Date(s) of activity (for raffles, indicate the date of the drawing) August 19,2007 Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ❑ `Bingo ® Raffles ❑ - Paddlewheels ❑ - 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 distributor, go to www.gcb.state.mn.us and ctick on List of Licensed Distributors. Or call 661 - 639 -4000. This form will be made available in alternative Your name and and vour organization's name the following: Board members, staff of the format (i.e. 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 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 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. 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 Board wnose wont assignment requires that they have access to the information; the Minnesota Department of Pubiic 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 are specifically authorized by state orfederal la to have access to the Information; individual and agencies for which law or legal orde authorizes a new use or sharing of information after this Notice was given; and anyone with yourconsent.