CCP 04-10-2007 - Laserfiche WebLink

Home Browse Search

.. ~_~ 4=~ -... • • Minnpcnfa / auvf'irl l~amf~linn Page 1 of 2 2/05 ~ For Board Use Only LG220 Application fior Exempt Permit Fee $50 Fee Paid An exempt permit may be issued to a nonprofit organization conducting lawful gambling activity on five orfewer days, and Check No. awarding less than $50,000 in prizes durings a calendar year. Organization Information Organization name Previous lawful gambling exemption number St. John the f3a fist Catholic Church 62159 Street City State/Zip Code County 835 2nd Avenue NW New Brighton - MN 55112 Ramsey Name of chief executive officer (CEO) Daytime phone number First name Last name (Rev.) NL~:chael Skluzacek (651) 633-8333 ext.1213 Type of Nonprofit Organization Type of nonprofit organization (check one) ^ Fraternal ®Religious ^ Veteran ^ Other nonprofit organization Type of proof of nonprofit status - attach a copy (see instructions) ^ Nonprofit Articles of Incorporation or Certificate of Good Standing -Minnesota Secretary of State's Office ^ Internal Revenue Service ^ Affiliate of parent nonprofit organization (charter) ® 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) St. John the Baptist School Address (do not use PO box) City dip Code _ County 845 2nd Avenue NW New Brighton 1~MI 55112 Ramse Date(s) of acfivify (for raffles, indicate the date of the drawing ) Ma.y 8, 2007 Check the box or boxes that indicate the type of gambling activity your organization will be conducting; ^ *Bingo ®RafFles ^ *Paddlewheels ^ *Pull-Tabs ^ '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.gcbstate.mn.us and click an List of Licensed Distributors. Dr call 651-639-400. 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 quaycations 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 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. Yourname and and yourorganization'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. If the Board does not issue you a permit, all the information you have provided in the process ofapplying for a permit remains private, with the exception of your name and yourorganization'soame 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 AttorneyGeoeral; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, natiohal and international gambling regulatory agences; anyone pursuantto wurt grder; other individuals and agencies that are specifically authorized by state nr 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 afterthis Noticewasgiven; and anyonewith your conserit.