10/11/1999 Council Packet - Laserfiche WebLink

Home Search

- Minnesota Lawful Gambling Application for Exempt Permit - LG220 Organization Information Page 1 of 2 10/98 For Board Use Only Fee Paid Check No. Initials Received � Organization name L iAjo 74k.e.5 G/ Previous lawful gambling s C /.46 'c4 exemption number Street ll City L/y s 3 6 / Lino Lakes State/hp Code County MN 55014 Anoka Name of chief executive officer (CEO) of organization First name ____., Last name )M as, Daytime phone number of CEO: ( 651 ) 23 / b L Name of teasurer of organization - First name /� ze,/,;„-k.„ name Daytime phone number of treasurer. (‘s—/ ) lJe� --"/ Type of Nonprofit Organization Check the box that best describes your organization: ❑ Fratemal 0 Religious ❑ Veteran j Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: ❑ 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 Name of premises where gambfi activity wit be condu ed (for raffles, list the site where the drawing will take place) ST ns-e -s C'�,l14 JO -- 6X. 6A T / LL Address (do not use PO boxl City State/hp Code County / t7/d)—\ S r C.! %./�!0 / .S MN 55014 Anoka Date(s) of activity (for raffles,. indicate the date of the drawing) doors-QA- / / , Check the box or boxes that indicate the type of gambling activity your organization will be conducting: - ❑ "Bingo [Raffles ❑*Paddlewheels ❑'Pull -Tabs ❑'Tpbcebs 'Equipment for these activities must be obtained from a licensed distributor. - - ... . . -. - -'- - - . —.. —.......,:I.hln illy to the This form will be made available in alterative format (Le. large print Braile) upon request. The information requested on this form (and any attachments) will be used by the Gambrmg Control Board (Board) to determine your qualifications to be involved in lawful gambfmg 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 aconsequence, 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. Al the other information that you provide will 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 piss of applying for your permit will become public. If the Board does not issue you a pemut, all the information you have provided in the process of applying fora pern it remains private, with the exception of your name and your organization's name and address which will remain public. 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 ofinfornation afterthis Notice was given; and anyone with your consent.