08-27-2003 Council Agenda - Laserfiche WebLink

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Paget of 2 06 /03 1n11 ir,ea1.1447 LawrMlr uraurun„y L3220 Application for Exempt Permit Fee $50 Fur Board Use Only Fee f aid CheokNo. Organization Information Organization name Previous 'avail] gambling exemption number Saint John's Church of Little Canada X- 62005 -03 -001 Street 380 Little Canada Road City Little Canada Statekip5o code Mn. 55 dy Cou It amse y Name of chow( executive officer (CEO) First name Last name Robert Fitzpatrick Daytime phone number of CEO Include area code (651) 484 -2708 Name of treaaurer First name Last name SAME AS ABOVE Daytime phone number of treasurer. Include area code Type of Nonprofit Organization Check the item that best describes your organization: Fraternal X Religious __ Veteran — Othernonprofitorganization Check the item that indicates the type of proof your organization attached to this application: IRS letter Indicating Income tax exermpt status � Certificate of Good Standing from the Minnesota Secretary of State's Office X 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 premiseswhere gambling activity will be conducted (for raffles, lie tine site where the drawing will take place) School Building Address (do not use PO box) 380 Little Canada Road City Little Canada Stale/zipcode Mn. 55117 County Ramsey Octets) of activity (for raffles, indicate the date of the drawing) Sunday, October 26, 2003 Check the Item(s) that Indicata the type of gambling activity your organization will be conducting: _x_ 'Bingo _ Raffles (cash prizes may not exceed 3(2,000) 'Paddlewheels 'Pull -Tabs _ °Tipboards 'Equipment farthing activities mustbe obtained from a Ileensod distdbutot, This form will be made available In altematNe format (Le, large print, Brellle) 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, 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 unit the Board Issues your permit, When the Board Issues your permit, all of the Intimation that you have provided to the Baird In the process of applying for your permit will become public. If the Board doer not Issue you a permit, all the Information you have provided in the process of applying fora 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 availabla only to the following: Board members, staff of the 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 am specifically authorized by state or federal law to have across 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.