12-15-1999 Council Agenda - Laserfiche WebLink

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f) Minnesota Lawful Gambling Permit _ LG220. Application for Exempt Organization Information Organization name Page 1 of 2 1019E For Board Use OM Fee Paid Check No. Initials Received Previous lawful gam in9 -xemptlon number v _ r0 l State/Zip Code County p9/Y Ss y 3 i /.* Al /4 Daytime phone number of CEO: ((OSl )� q S /' Daytime phone number of treasurer ((/ ) (Ho o ara- T ci ANA S° City sr 51.011 �. NG 7°'y Streeet -rm. -5v o w q s of organization Name of chief executive officer (CEO) organization First / Fr 14 (Z) STv P HE a G R E. b Lv r7 Last name c0K,E' !CA- Name of teasurer of organization First name TOSE- tt _ npro anization =� _.:•:. Type of Mc Wrofit.Org anization: ' Check the box that best describes yodr'org ❑ Fraternal ❑ Religious Other nonprofit organization ❑- Veteran Ration attached to this application: Check -the box that indicates the type of proof your org an ❑ IRS letter indicating income tax exempt status ❑ Certificate of Good Standing from the Minnesota Secretary of State's Office 0 A charter showing you are an affiliate of a parent nonprofit organization la Proof previously submitted and on file with the Gambling Control Board name Premises Information will be conducted (for raffles, fist the site where the drawing will take place) Name of premises where G r gambling I N County State/Zip Code MN Address (do not use PO box) V � 5 7 City l Dat e (s) of activity Or raffles, indicate the date of the drawing) 000 E U e of gambling activity your organization will be conducting: Check the box or boxes thaa files to the 0 *Paddlewheels ' ❑ "Pull - Tabs ❑ "Bingo (Raffles - _ obtained from a licensed distributor.: 1 you are *Equipment for these activities must and and your organization's st be obtai available only to the me Private data abou y Your name a public information name following:. Board members, staff of the Board oave received the will be Board. blce formation when whose work Board members, requires staff of information form will q made available in alternative inform(tion request,Bran this form (and The and address will be P you acdess to the information; the Minnesota information requested on this form (and any that you provide will be private data about y Department of Pubic Safety; the Minnesota will be used by the Gambling Y permit. When the General; Public Safety; the Minnesota a attachments) of Administration, Finance, and Revenue; the Control Board (Board) Board issues your permit all of the information • Attorney Board to determine your until the Board issues your Minnesota Legislative Auditor, national and qualifications to be involved in lawful gambling ternational gambling regulatory agencies; You • have the right to that you havelPn for our permiittvrill become ,Ial and activities in Minnesota. 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. process of app Y 9 public. If the Board does not issue you a permit, m for a have provided private, and agencies that are specifically authorized by all the information you have provided tin the anyone pursuant to courtorder,other in process of applying with the ion's exception name of your name and your information; i i order authorizes agencies f use organization's name and address which will sharing oor legal order authorizes a new aese'e or remain public. and anyone with Your consent. Page 168