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

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Minnesota Lawful Gambling t Permit APP for Exemp An exempt permit maybe issued to a nonprofit organization conducting lawful gambling activity on five or fewer days, awarding less than $50,000 in prizes durings a calendar year Organization Information Organization name Street Name of chief executive officer (CEO) First name Page 1 of 2 2106 For Board Use Only Fee $50 Fee Paid Check No. Previous lawful gambling exemption number X fZ 3 I y k 3 County J State2ip Code City MA/ f.fyz 114 r o ' n/ si Daytime phone number Last name C� S 41 3-�Z to d v2Zi Type of Nonprofit Organization Type of nonprofit organization (check one) ❑ Fraternal ❑ Religious ❑ Veteran [ Other nonprofit organization Type of proof of nonprofit status - attach a copy see instructions) of State's Office tion or Certificate of Good Standing - Minnesota Secretary ❑ Nonprofit Articles of Incorporation ❑ internal Revenue Service ❑ Affiliate of parent nonprofit organization (charter) Control Board Proof previously submitted and on file with the Gambling Gambling Premises Information will take place) Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing •' ' se Address (do not use PO box) f tivity (for raffles, indicate the date of the drawing) Zip Code 3 D 31 County /Vp K/ /YI Al Dates) o ac O_ a D G 7 0 7 our organization will be conducting: Check the box or boxes that indicate the type of gambling activity y * T bs ❑ *Tipboards ��II ❑ *Paddlewheels ❑ Pull- a ❑ *Bingo [,J Raffles * dl (bingo *Gambling eq uipment for pull -tabs, and bingo ( paper, hard cards, and bingo ball g pContro mbling eq tipboards, paddlewheels p the Gambling l Board. To find a licensed A must be obtained from a distributor licensed by or, o to vvww.gcb.state.mn.us and click on List of Licensed Distributors. Or call selection 1151- 639 -4000. distribut , g This form will be made available inoan request. The format (i.e. large print, Braille) up The information requested on this form m(and ng any attachments) will be used by the 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 qualification toss you a Consequence, may refuse permit: If you supply the information requested, the Board will be able I process your application. 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 informatio oa permit ovided in the process of a ppl y in g fo 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 0 • th 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 Legislatnve 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 the information; individuals and agencies for which law o l egal ord authorizes a new use or sharing of after this Notice was given; and anyone with your consent. _22_