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6amoling Contra! Surd =ax :651-639 -4073 <br />Nov 15 '00 10 :57 P.06 <br />Minnesota Lawful Gambling Fur ease uaa Only <br />LG220 - Application for Exempt Permit 'Fee - <br />Page t of 2 8100 <br />Organization Information Crook No. <br />Orgenctatco 1 name PteVioua lawful gambling exemption number <br />kl i N/9 E S v ?,4 091-7 c I AN s -Sc /c,- x_t,za 146 _00 --001 <br />Street <br />w4Srtfsr_ <br />City <br />3..40dite /AC row <br />StetefZip Code ' <br />_MN S'Ll31 <br />County <br />1- 6'NAinry <br />Name of chief executive officer (CEO) <br />First name Last name <br />J.I,4Nc. L( KNJDTJ1 • <br />_1- <br />I Daytime phone number of CEO <br />6/2 ??3 l790 <br />Name of treasurer <br />First name Last name <br />a e► . aK) <br />Daybtn* phone number of <br />treasurer. <br />( ;SY6o 2 <br />Type of Nonprofit Organization <br />Chock the box that teat describes your organization: <br />• Fraternal ❑ Relgbua <br />❑ Velareat fia Cetar nonprofit organization <br />Check the box that Indicates the type of proof your organization attached to this application: <br />❑ 'RS teary Indicating inborn* tax exempt status <br />❑ Certificate of Good Standing from the Minnesota Secretary of State's Office <br />iiA oharter showing you are en affiliate of a parent nonprofit organbation <br />Proof previously submitted and on fie watt the Gambling Control Board <br />Gambling Premises information <br />Name of promises where gamorng aZWlhr wet be conciliated (feu fades. lit thong when Inc drawnq WI take place) <br />1'1)E V FN_ At EIS/ <br />Address (do not rya PO bed <br />?$ I Y A LC F Sr <br />City <br />1 trlaic a5aesit:q <br />Staro2lp Code <br />Jo <br />County <br />RAM<SZ e <br />stow of acne, (tot Totes, tn* w me ugte Mule wiWingl <br />FE2 LLAa(f' L? TeJ 'OQf <br />Cheek the box or coon that indicate the type of gambling act/dy your organization wrll be conauotng; <br />❑'singe RFtaffamt ❑ "PaddIawheei ❑•Fu$Tabs Ili 'Tlpboards <br />'Equipment for thew activities must be ebtarted from a Ikemad demurer. <br />T'hla torrn will be made svallible In <br />alternative format (La, large print, Broil*) <br />upon request. The biferrrreaon ragueatad <br />on this form (and any etmetanafro) wit be <br />used by the Gambling Control Board <br />(8owd) to datatmhe your qualifications to <br />be involved In !swag bombing Winkles in <br />Minnesota You haw the Matto Muse to <br />a upptyme lefonratlon requested; howettl, <br />1 y0u refuse to suppymla k ftmfatort. tie <br />Board may not be ern to detammee your <br />qua$ae60nsand, no consequent* may <br />refuse to Ssueyou a penrta if supply <br />tea in iami:ton requested. tha aoazd wed <br />boob* to process your application. <br />Zfl 39tid <br />Your name and and your organrndon'a <br />name and addroeawa be public ktbrntarlen <br />ens received byrhalabard. Mt thebmar <br />'nformaean ma you proi4de mil he PIMA* <br />data about you unable Boom tsa/es your <br />parmtt. When the Board la0uq your <br />Derma a8 trite internment thatyou haw <br />prwasa to the board in tha proms of <br />applying taryanpennawabemmepun8c. <br />If the eoard Ones not issue you a permit, <br />/acne nfomadal you haQ aiottaad lathe <br />pros • 01 appbng for a pamtit irons <br />private. with Um axapdon of your name <br />and yourorgantanza nl nanuand wdraaa <br />gallop vAl merlin Public. <br />Pnvaredata mboutyOU are mailable onNto <br />-tYOI1dO 3- itu -I1nOS <br />Page 11 <br />the idtlowenq: aimed members, staff otlho <br />Hoard whose work assignment tarmacs <br />that they have aeons to tIe information: <br />th.Mbineata 0aparbnm4 et Rube, Safety; <br />the Minnesota Attorney General: the <br />Minnesota Commtsaioners of <br />Admk+Ntration, Finance, and Annuli, mo <br />Mnnesotst agcttaWAUdit0t; nationaland <br />international bombing regtllatbry Aganpfi <br />abyona pursuant to court order, other <br />Individuals and agencies that are <br />vomitory suthadzd by state or fattiest <br />law to nave access to am Information; <br />individual* and agencies for which law or <br />kgat ardsraullion:um a new moor antra <br />of nt:motion otter this Nonce Wasgluon; <br />and anyone with your consent. <br />abLSSZSZT9 0E :60 000Z/0Z/TT <br />