5.5. SR 11-24-2003 - Laserfiche WebLink

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Minnesota Lawful Gambling LG220 Application for Exempt Permit Fee $50 Organization Information Page 1 of 2 (web) 6/03 tFor Board Use Only Fee Paid Check No. Organization name Street ~ cO. ~ ~ ~2 0 / Name of chief executive officer (CEO) First name Name of treasurer Fimt name City ! Last name Last name Type of Nonprofit Organization Previous lawful gambling exemption number I State/zip code I County Daytime phone number of dEO Include area code Daytime phone number of treasurer. Include area ~ode Check the item that best describes your organization: Fraternal ~' Religious Veteran __ Other nonprofit organization Ch~k the item 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 Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) Address (do not use PO box) [ City '/ I Date(s) of activi~ (for raffles, indicate the date of the drawing) Check the item(s) that indicate the ~pe of gambling activi~ your organization will be conducting: ~ *Bingo ~ Raffles (cash prizes may not exceed $12,000) *Paddlewheels *Equipment for these activities must be obtained from a licensed distributor. I State/zip code [ County I __ *Pull-tabs *Tipboards This form will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) will 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 ~ay 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. Your name and and your organization's name and address will be public information 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, l:f the Board does not issue you a permit, all the information you have provided in the process of applying for a 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 the 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 of information alter this Notice was given; and anyone with your consent.