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. . . Minnesota Lawful Gambling LG220 Application for Exempt Permit Page 1 of 2 (web) 12!C3 For Board Use Only Fee $50 Fee Paid Organization Information Check No. Organiz8tion name Previous iawfu! gambling exemption number . St~!:~~L}dn)~ l~-:!L\ I}? t/--t!_'71 ,~~J~~'J/e)fziJ 4l"01~Stat~iZi;t':d~) '?2c3ct:nt~3 -~QCL _ /J ! I .~~ J._ ~ , J:?-~CL__iQ?_5~?~~(______/ViuJr5rl'C"nl-r-vt __ _~_~~~ /fJ./}_ :i_i""/L-:;~ 6a.n"S(:~1.____ Name of chief executive officer (CEO) J T I First name Last name I Daytime phone number of CEO ____,dr:."4/e.r/-!;___ n_------/-#Jh_P,,;)s.1: ~___ _ ______ .1.__ e~1. -._~;_}3 - /~_?-- ~ Name of t:'8Clsurer Daytime phone number of Fi~~name Last name treasurer: JC-i;;.r} Crdu;k~/ c,-'s'I-t:~3/-ffCJS7 Type of Nonprofit Organization Check the box that best describes your organization: D FrClternal D Religious D Veteran 8J Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: D IRS ietter indicating income tax exempt status D Certificate of Good Standing from the Minnesota Secretary of State's Office D A charter showing you are an affiliate of a parent nonprofit organization D Proof previously submitted and on file with the Gambling Control Board Gambling Premises Information f\:,F,iC of ~,rsmis,:;s where gambling activity will be conducted (for raffies. list the site where the dra'Ning will take place) 01 ' · "'dd;;,;(~;~,~o~,~'L C'y f~'---'~ S;;';iZ'~ Co"- . 1~-~~~;Y- -------- __2.;2_Cc.' _!.._~jlt{,1d..,,- / C" /)7c--c-'----:rlc!j V!c:-w ;J1// t\a'1'11.5c?Y.. Da!e(s) C'f activity (~or raff:es~t1dicate the date of the ci-ia;,:.;:ing)-------- ----- p' - ------ - - - - ----::J- ---- .~-----,---,---~~t:;/i::.":~.'1' . (;'I"--!-~l .3._?;~_J-_:2. c' c t~ -------,--------c-;--.. "__-'-'" _____ Lh,;cK me bo>: Dr Doxes tnat Indicate the type of gambling activity your organ:zatlOn will be conducting: lli"~'E3ingo [II Raffles (cash prizes may not exceed 512,000) D'Paddiewhcels D -Puil-Tabs D *Tipboards -Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball selection device) mllst be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor. go to www.gcb.statc.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. This inrrr' ViiI! bc~ n~~Kle available in 8ltern3tive Torme:: (:.~~.la:ge prlnt. Br(~i!le) upor~ request. Tr1e jnbrr~V1ti()r; iE:qLH-~sted an :1"1:s forrn (::uld ar~y Eltta:>~n8r.ts.;' wi\l tie used by the G(1nlbling Cori~ro: 3C)ard (Board) to deterrni:le your (~ualif!c~1tion~... to b8 i~lV()lved in lav:ful gambling acti'/it![;3 ir. rv1jl~nesota. You hDve the right to r~fuse 1:) SU~:iP!Y t~'E::' irrfoITnatton requested; hovvever: if YC:L refuse to supply this inforrf',3tio:-,., the f30ard n18V not be able to (L-~tertTiine y~)ur quc;llflcZltidns ard, as a cor.S!:.~qucnce, nlay refusE~ to issue you a YOJ.Jr name and and y:)ur organization's narT1C and address v-JiH be public jt~fOrrn8tion v/r.sn received by the aoard. AI! tre other info:TT1atio1 that you provide 'Ivill ~'Je ;xivate Gata about yC)U until the Board issues your perrnit. \:'\!r-is~; the Board issues yot.:r permit ail of the info~iT1?tion that you haVE: pr:Jvided to the Board in tt-;8 process of applying for your permit will beC0:-11~ public. If the Board doe:> not issue you :3 permit. aU the information you hav~ pro\!i:kd in th2 process of opplying for a permit r-::~;:'iai::s private, \vi:b the excc:ption of Y'Jur r~am;~ and your Q:;j3iiz.atic>t:'s n8.nlC 8t--=d accirc~s~ Which lhe follov!infJ: Board n-lernbers, staff of the Boarc w~sse work assi;:]nmcnt requires that tr'ey have access to the information; the l\k~~1eS()ta Department of Public Safety: the MinnesotCi/'\ttorney General: the Minnesota Cornrnissioners of Administration. Finance, and Re\/cnue; the ~\1inneS;Jt3 Leg~s:lative Auditor. na~ional and international gl..!rnbiing regu:atory agencies; C1nyone pursuant,,? court a~der-: other individua!s ann agcncie:. ~~.I~lt are specifically authorized by state or federallav'/ to ha\"e aCCCf;S to the: lr:formatjon; individuc.lls anti 2gsnC\es for \:vhich l2W or !e.;J8! orr.1f"::r auir.Gil?f.;;; ? ne\,v use cr shari~g af irformc.tion c.ifter tr~is \~cH"ice was ;;ivsn: a:i~ ar'yonc with 'Oe;-rni~. if \!(.lU 3u;:-,piy tn!.:.: infD;--rnati()~1 r:~:.~~l)L:~;ICC. ~h{:; 8(,<~rc vvin [;(; i-lt:k:; tc proc.ess 'your :':l;)~:.i:;~Xc:-':. \vii] n~rn8in ~u::'~~:. Prj\...(.)t~: 08;.3 abOlJt you a:-c avaiiZ:ib!e only ~i) /::U," :;onsent.