Agenda - Council - 03/11/2003 - Laserfiche WebLink

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Page 1 of 2 ':""~'-avwU~ Gambling I For Board Use Only Minnesota LG220 ApPlication for Exempt ru~m,t Fee - $25 FeePaid I Orrmni7~tinn Infnrrn~tinn I Check No. Organization name Previous lawful gambling exemption number 3/01 -I Street 'O ICily I State/Zip Code I County bo. lo I Name of chief executive-e~'icer (CEO) First name Last name ' Daytime phone number of CEO Name of treasure~ First name Last name Type of Nonprofit Organization I Daytime phone number of {. treasurer: 9e% ~ q~- glo. 90 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 to this application: [] IRS letter indicating income tax exempt status [] Certificate of Good Standing from the 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 Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) [ Addr-'~ss (do not use PO box) ' City ' I State/Zip Code County t Oate(s) of acti~ ~r ra~es, indicate the date of the dmwin~ . I q, . ~e b°x °~at indicate the ~e Of gambling activ~ ~ur Organ~On will be conducting: __~ ~ *Bfngo ~Raffies (cash p~es may not exCe~ $12,000) ~ *Paddlewh~ls ~*PulkTabs ~Tipboards *Equipment for these activities must be obtained from a licensed distributor. This form will be made available in Your name and and your organization's the following: Board members, staffofthe I I I I I I I I I I I I I I altemative 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 dghtto refuse to supplythe information requested; however, if you refuse to supplythis 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 bythe 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 nameand address which will remain public. Private data about you are available onlyto Board whose work assignment requires that they have access to the information; the Minnesota Depadment of Public Safety;, the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and intemationatgambling 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 or legal order authorizes a new use or shadng of information after this Notice was given; and anyone with your consent. -44-