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<br />I <br /> <br />Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit <br /> <br />Page 1 of 2 2/06 <br /> <br />Fee $50 <br /> <br />For Board Use Only <br />Fee Paid <br />Check No. <br /> <br />An exempt permit may be issued to a nonprofit organization <br />conducting lawful gambling activity on five or fewer days. and <br />awarding less than $50,000 in prizes durings a calendar year. <br /> <br />Organization Information <br />Organization name <br /> <br />15".('1 <br /> <br /> <br />Previous lawfu/gambling exemption number <br />c:LV-A <br /> <br />~w <br /> <br />Name of chief executive officer (CEO) <br />First name <br /> <br />4-~ <br /> <br /> <br />StatelZip Code <br />S-S; <br /> <br />Daytime phone number <br />1/ 9""1,1/ r 5 ~ J'B'CJ~ <br /> <br /> <br />Last name <br /> <br />Type of Nonprofit Organization <br /> <br />Type of nonprofit organization(check one) <br />o Fraternal 0 Religious <br />o Veteran ~ Other nonprofit organization <br />Type of proof of nonprofit status - attach a copy (see instructions) <br />o Nonprofit Articles of Incorporation or Certificate of Good Standing - Minnesota Secretary of State's Office <br />D Internal Revenue Service <br />o Affiliate of parent nonprofit organization (charter) <br />~ Proof previously submitted and on file with the Gambling Control Bo~rd <br /> <br /> <br />vA. <br /> <br />Zip Code <br /> <br />County <br /> <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br /> <br />J 4,- -;;? tJ~~ <br /> <br /> <br />Check the box or boxes that indicate the type of gambling activity your organization will be conducting; <br /> <br />o *8ingo ~Raffles 0 *Paddlewheels 0 *Pull-Tabs 0 *Tipboards <br /> <br />*Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bIngo paper, hard cards, and bingo ball <br />selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed <br />dIstributor; go to www.gcb.state.mn.us and click on List of Licensed Distributors. Or call 651-639-4000. <br /> <br />This form will be made available in alternative <br />format (Le./arge print, Braille) upon request. <br />The information requested on this form (and <br />any attachments) will be used by the Gambling <br />Control Board (Board) to determine your <br />qualifications to be involved in lawful gambling <br />activities In Minnesota. You have the right to <br />refuse to supply the information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able to <br />determine your qualifications and, as a <br />consequence, may refuse to Issue you a <br />permit. If you supply the information <br />requested, the Board will be able to process <br />your application. <br /> <br />Your name and and your organization's name <br />and address will be public information when <br />received by the Board. All the other Information <br />that you provide will be private data about you <br />until the Boardissues your permit. When the <br />Board issues your permit, al/ of the information <br />that you have provided to the Board In the <br />process of applying foryour permit will become <br />public. If the Board does not Issue you a <br />permit, all the Information you have provided <br />In the process of applying for a permit remains <br />private, with the exception of your name and <br />your organization's name and address which <br />will remain public, <br />Private data about you are available only to <br /> <br />the following: Board members, staff of the <br />Board whose work assignment requires that <br />they have access to the information; the <br />Minnesota Department of Public Safety; the <br />Minnesota Attorney General; the Minnesota <br />Commissioners of Administration, Finance, <br />and Revenue; the Minnesota Legislative <br />Auditor, national and International gambling <br />regulatory agendes; anyone pursuant to court <br />ordE;lr; other individuals and agencies that are <br />specifically authorized by state or federal law <br />to have access to the information; individuals <br />and agencies for which law or legal order <br />authorizes a new use or sharing of Information <br />after this Notice was given; and anyone with <br />your consent. <br /> <br />