06-11-2003 Council Agenda - Laserfiche WebLink

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Page 1 of 2 3/01 LG220 Application for Exempt Permit Fee - $25 Per Board Use Only Fee Paid Organization Information Check No. Organization name /; Pregviious lawful gambling exemption / / ilk.' ; iCo '�t'�(, ;7if ??6.:1. %(0/Li /77/,-5- ` :I1,1 ! /i>i'�% number Street /i /2/77 (7 i7 Vii City ,� % %j i ��.; ..; � it State/Zip Code l/ / <37/ / County ��1� /2-27S-96.7 Name of chief executive officer (CEO) First name Last name /61/16# moo, 25 ar Daytime phone number of CEO 6/2)}G '73 C ? -31 v Name of treasurer First name Last name Daytime phone number of treasurer: 71V--,2252. 9 Type of Nonprofit Organization Check the box that best describes El Fraternal ❑ ❑ Veteran Check the box that indicates the rj IRS letter indicating income Certificate of Good Standing ❑ A charter showing you r Proof previously submitted your organization: Religious Other nonprofit organization type of proof your organization attached to this application: tax exempt status from the Minnesota Secretary of State's Office are an affiliate of a parent nonprofit organization and on file with the Gambling Control Board Gambling Premises Information Name of pr r/emises where gambling activity will be conducted (for raffles, list the site where the drawing wit take place) Address (do not use PO box) z /CcT City /17-779.- riada iMN State/Zip Code 55717 County 727 -1?9- Date(s) of activity (for raffles, indicate the date of the drawing) Check the box or boxes El. *Bingo *Equipment for these that indicate the type of gambling activity your organization will be conducting: Raffles (cash prizes may not exceed $12,000) ❑ *Paddlewheels n "Pull-Tabs ❑ 'Tipboards activities must be obtained from a licensed distributor. 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 qualifications to be involved in lawful gamblina 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 wit 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 wit 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 name and address which will remain public. Private data about you are available only to 2 the 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 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 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.