02-28-2001 Council Agenda - Laserfiche WebLink

Home Browse Search

Gambling Control Board Fax :651- 639 -4073 Min Feb 15 '01 1534 P. 02 Page 1 of 2 8/00 - - -- -e LG220 - Application for Exempt Permit Fee - $25 Forerun' Use Only F « Pala Organization Information Check No, O anization name Previous lawful gambling exemption number flOgineg 0 Off OS op fl4C.ser: AUcCf p-' &CAQUi it, Itac. Street /4q0 scam I-r-/ . City Staterrap Code s-c +Aut MN 567oS County r 1f'ImhSeV Name of chief executive officer (CEO) First name Last name C',NR .. Di etNiooK Daytime phone number of CEO /pl a 613 4V: Name of treasurer First name Last name NOS muRPAY Daytime phone number treasurer: 461 - 69& -31a1 of Typo of Nonprofit Organization Check the box that best describes your organization: ❑ Fratemal ❑ Religious ❑ Veteran PKI Other nonprofit organization Check SS box that indicates the type of proof your organization attached to this application: J 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 11 -1€ UFl)f4lAN IPa0 wit be conducted (for raffles, rat the site where the drawing we take place) Address (do not use PO box) -?R ('/ «I C. 9f. City (.1fic . C.ANIk0A State/ip Code MN 56(13 County Rlk y Date(s) of activity (for raffles, indicate the date of the drawing) mARCtk a6) a031 Cheek the box or boxes that indicate the type of gambrmg activity your organization will be conducting: ❑ -Bingo igfRaffles ■ 'Paddlewheels NI 'Pull-Tabs ❑Tipboards 'Equipment for these activities must be obtained from a licensed distributor. This form will be made available in altemative format (Le. large print, Braille) upon request The information requested on this form (and any attachments) we be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambing activities in Minnesota. You haw the right to refuse to supplythe information requested; however, if refuse to supply this information, the Board may not ba able to determine your quaffiratione and. as a consequence, may refuse to issue you a permit. if you supply the information requested, the Board war be able to process your application. Your name and and your organization's name and address wit be pubic information when received by the Board. AN the other information that you provide wit be private data about you until the Board Issues your permit. When the Board issues your permit, el of the infonnadon that you have provided to the Board In the process of applying for your permitwil become public. If the Board doss not Issue you a permit, all the information you have provided in the process of appying for a pwmti remains private, with the exception of your name and your organization's name and address which we remain public. Private data about you are available only to Page 36 thetoMowing: 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 Commiesioners of Administration, Finance, and Revenue; the Minnesota LegtchlhreAudltor, national and ittemafionat gambing regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifca i authorized by state or federal law to haw access to the mformabon; 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.