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Apr 06 06 01:59p Sisters of St Francis S~l . Minnesota Lawful Gambling LG220 Application for Exempt Permit 419 824 3626 p.2 Page 1 of 2 2J06 Fee $50 For Board Use Only Fee Paid_~.__ An exempt permit may be issued to a nonprofit organization conducting lawful gambling activity on five or fewer days, and awarding less than $50,000 in prizes durings a calendar year. Organization Information Si'St".t.,-:2S LIP 5t-. rfi.-6.J.u,/s Organization name Previous lawful gambling exemption number Check No_ e, '1 Str t t f 3 '2 C'/'J J.:::rt t i1iv-C' Name of chief executive officer (CEO) First name ( i . Type of N I nprofit Organization Type of nonprofit organization (check one) D Fraternal IiZI Religious D Veteran 0 Other nonprofit organization Type of proof of nonprofit status - attach a copy (see instructions) D Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office D Internal Revenue Service D Affiliate of parent nonprofit organization (charter) o Proof previously submitted and on file with the Gambling Control Board Last name Daytime phone number - 3 (,/8 . Gambling Premises Information Name of premises where gambling activity will be conducted (for raffles,list the site where the drawing will take place) .JUI k. C-;; .'2-t:-.t-.rtdU:L-t:AL__J311 Address (do not use PO box) Zip Code County '(5-// ~ ox or boxes that indicate the type of gambling activity your organization will be conducting: I2l Raffles 0 'Paddlewheels 0 'Pull-Tabs D wTipboards 'Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball selection devjce) 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. . This form will be made available in alternative format (Le.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 may nol 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 infomlation that you provide will be private data about you until the Board issues your permit When the Board issues your permit, all of the infomlation 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 !he process of applying for a pemlit 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 !hey 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 h;;Jve access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing ofinformation after this Nolicewas given: and anyone with your consent.