08-24-2005 Council Agenda - Laserfiche WebLink

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Page 1 at 2 06 /03 L0220 Application for Exem t Permit Fee $50 P P P FeePaerduae0nly Fee Paid Organization Information CheckNo, Organization name Previous lawful gambling exemption number Saint John's Church of Little Canada X- 62005 -05 -001 Street 380 Little Canada Road City Little Canada State/zip code Mn. 55117 County Ramsey Name of chief executive officer (CEO) First name Last name Edward Bohier - Daytime phone number of CEO Include area code 651 484 -2708 Name of treasurer First name Last name same as above - Daytime phone number of treasurer. Include area code Type of Nonprofit Organlzatlon Check the item that best describes your organization: _ Fraternal ,x, Religious _ Veteran Other nonprofit organization Check the item that indicates the type of proof your organization attached to this application: IRS letter Indicating Income tax exempt status — Certificate of Good Staitd(ng from the Minnesota Secretary of State's Office XX A charter showing you are an affiliate of a parent nonprofit organization _ Proof previously submitted and on file with the Gambling Control 9oard Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, lie the site where the drawing will take place) Church grounds Address (do not use PO box) 380 Little Canada Road. l City Little Canada State /zip coda Mn. 55117 County Ramsey Data(s) of activity (for raffles, indicate the date of the drawing) Sunday, September 25, 2005 Check the item(s) that indicate the type of gambling activity your organization will be conducting: X 'Bingo — Raffles (cash prizes may not exceed 812,000) — 'Paddlewheels y 'Pull -Tabs _ "Tipboards 'Equipment for these activities must be obtained from a licensed dIsttibutor, This form will be made available in 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 qualification 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. 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 pro +ide will be private data about you until the Board Issues your permit, When the Board Issues your permit, all of the Intimation that you have provided to the Boird in the process of applying for your pent it will become public. If the Board doe; not Issue you e permit, Ml the Information 'mu have provided in the process of applying for a permit remains prvatt, with the uscaptinn of your name and your organtzatIon's name and address which will remain public Private dad about you are availallle only to the fallowing: Board members, staff of the snare 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 Adminiabetion, 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 haw aces to the 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.