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Minnesota Lawful Gambling Page 1 of 2 11/04 LG220 Application for Exempt Permit Fee $50 For Board Use Only An exempt permit may be issued to nonprofit organizations conducting lawful gambling activity on five or fewer days, and Fee Paid_,______ awarding less than $50,000 in prizes during a calendar year. Check No. Organization Information Organization legal name < Previous license or exemption number, if any :r. �n�l�Vf or?y, V i 110 JjJU Street 5 City State and zip code // rre�ft County Name of chief executive officer (CEO) First name Last name Daytime phone number ------------ 781 _M9 c� Type of nonprofit organization (check one) ❑ Fraternal ❑ Religious ❑ Veteran �, Other nonprofit organization Type of proof of nonprofit - attach a copy (see instructions) �R"-Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office ❑Internal Revenue Service ❑ Affiliate of parent nonprofit organization (charter) Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site whore the drawing will take place) Vie-- oI Address ((doo not use PAL) Qty Zip code County i f I' C l' /I�c; l� c I I� f-1�l�iy,� Date(s) of activity (foi raffles Indicate the date of the drawing) ,200 Check the box or boxes that indicate the type of gambling activity your organization will be conducting: ❑'Bingo XRaffles ❑ `Paddlewheels ❑ `Pull -Tabs U 'Tipboards 'Gambling equipment for pull -tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed distributor, go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. Tfiis form will be made available in alternative Your name and and your organization's name the following: Board members, staff of the rormat p.e. Targe print, tuame) upon request, The information requested on this form (and any attachments)wilI be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling 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 arid, 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. one aooress wtll be rustle Imermatlon when received by the Board. All 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 process of applying for your permit will become public. If the Board does not issue you a permit, all the information you have provided in the process of applying fora permit remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are available only to 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 of information aftor this Notice was given; and anyone with yourconsent. M