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<br />LG220 Application for Exempt Permit Fee $50 For Board Use Only <br />Fee Paid <br /> -- <br />Organization Information Check No. <br />Organization name Previous lawful gambling exemption number <br /> New Brighton Eagles Auxiliary 3930 <br />Street City State/zip code County <br /> 563 Old Highway 8 NW Ne.w Brighton~ Mn 55112 ramsey <br />Name of chief executive officer (CEO) Daytime phone number of CEO <br />First name Last name Include area code <br />Beverly Menk 651 633 7196 <br />Name of treasurer Daytime phone number of <br />First name Last name treasurer. Include area code <br />Rosie Peterson 651 636 9525 <br /> .. <br />Type of Nonprofit Organization <br />Check the item that best describes your organization: <br />X-- Fraternal _ Religious <br />- Veteran _ Other nonprofit organization <br />Check the item that indicates the type of proof your organization attached to this application: <br />_ IRS letter indicating income tax exempt status <br />_ Certificate of Good Standing from the Minnesota Secretary of State's Office <br />_ A charter showing you are an affiliate of a parent nonprofit organization <br />~ Proof previously submitted and on file with the Gambling Control Board <br />Gambling Premises Information <br />Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place) <br />New Brighton Eagles Club <br />Address (do not use PO box) City State/zip code County <br />563 Old Highway 8 NW New Brighton~ Mn Mn 55112 Ramsey <br />Date(s) of activity (for raffles, indicate the date ofthe drawing) <br /> November 26 ~ 2006 <br />Check the item(s) that indicate the type of gambling activity your organization will be conducting: <br />- *Bingo X- Raffles (cash prizes may not exceed $12,000) _ *Paddlewheels _ *Pull-Tabs _ *Tipboards <br />*Equipment for these activities must be obtained from a licensed distributor. <br /> <br />. <br /> <br />Minnesota Lawful Gambling <br /> <br />. <br /> <br />. <br /> <br />This form will be made available in <br />alternative format (i.e. large print, Braille) <br />upon request. The information requested <br />on this form (and any attachments) will be <br />used by the Gambling Control Board <br />(Board) to determine your qualifications to <br />be involved in lawful gambling activities in <br />Minnesota. You have the right to refuse to <br />supply the information requested; however, <br />if you refuse to supply this information, the <br />Board may not be able to determine your <br />qualifications and,as a consequence, may <br />refuse to. issue you a permit. If you supply <br />the information requested, the Board will <br />be able to process your application. <br />Your name and and your organization's <br /> <br />name and address will be public <br />information when received by the Board. <br />All the other information that you provide <br />will be private data about you until the <br />Board issues your permit. When the Board <br />issues your permit, all of the information <br />that you have provided to the Board in the <br />process of applying for your permit will <br />become public. If the Board does not issue <br />you a permit, all the information you have <br />provided in the process of applying for a <br />permit remains private, with the exception <br />of your name and your organization's name <br />and address which will remain public. <br />Private data about you are available only to <br />the following: Board members, staffofthe <br /> <br />Page 1 of 2 <br /> <br />06/03 <br /> <br />Board whose work assignment requires <br />that they have access to the information; <br />the Minnesota Department of Public <br />Safety; the Minnesota Attorney Generali <br />the Minnesota Commissioners of <br />Administration, Finance, and Revenue; the <br />Minnesota Legislative Auditor, national and <br />international gambling regulatory agencies; <br />anyone pursuant to court order; other <br />individuals and agencies that are <br />speCifically authorized by state or federal <br />law to have access to the information; <br />individuals and agencies for which law or <br />legalorder authorizes a new use or sharing <br />of information after this Notice was given; <br />and anyone with your consent. <br />