Agenda - Council - 01/28/2003 - Laserfiche WebLink

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I I I I I I I I I. I I I I I I I I I Minnesota Lawful Gambling LG220 Application for Exempt Permit Fee- $25 Organization Information Page 1 of 2 3/01 'F'or Board Use Only Fee Paid Check No. Organization name Previous ~awful gambling exemption number Street ' ' ' Ci~ ' " state/Zip Code I Name of chief executive office~ (CEO) First name Nam~ o~f' t~r~a~,u~'~r ' ' First name Type of Non'p'r°fit Organization Last name Last name Oaytime phone number of CE° Daytime phone number of treasurer: 7r -- 593- ,¢' .%' Check the box that best describes your organization: [] Fraternal [] Religious [] Veteran ~Other nonprofit organization Check the. box that indicates the type of proof your organization attached [o this application: ~ IRS letter indicating income tax exempt status [] Certificate of Good Standing fromthe Minnesota secretary of State's Office [] A charter showing you are an affiliate of a parent nonprofit organization [] Proof previously submitted and on file with the Gambling Control Board Gamblin~l Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Dat~s) 6f ~cti~ (fo~ rames, indicate tag date of tag drawing) [ '" ~ - Check the b~ ~ b~xe~ that indic~t~ t~e ~e.of gambling actb~ your organization will be conducting: ~ *Bingo ~Raaes (cash p~zes may not exce~ $12,000) ~ *Paddlewheels ~ *Puli-Tabs *Equipment for these activities must be obtained ~om a licensed distributor. This form will be made avail.able in. Your name and and your organization's [] *Tipboards the following: Boar~ members, staff of the alternative 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. name and address will be public information when received by the Board, All the other information that you provide will be pdvate 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 pdvate, 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 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 are specifically authorized by state or federal law to have access to.ti~e 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. -25-