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I <br />05/07/2003 14:03 6516905203 GRAY*STIMSO PAGE 05 <br />MinnosoUi Lawful Gambling <br />LG220 Application for Exempt Permit Fee • $25 <br />Organization Information <br />Page 1 of 2 S/DI <br />For Board Use Only <br />Fee Paid <br />Check No. <br />levlous lawful gambDng exemption number <br />J ____r- <br />Staie/ZB Cod^ <br />Name of chief executive officer (CEO) <br />First name <br />5ameoMft <br />/p Lwtnarje <br />Name of tfeasurer <br />First name Last name <br />Daytime phone number of CEO <br />Daytime phone number of <br />Typa of Nonprofit Organization <br />Check the box that best descrtoes your organizat'ion; <br />0 Fraternal O Ra^us <br />Q Veteran Ip^Otfier nonprofit organization' ~ <br />Check thepex that indicates the type of proof your organization attached to this application: <br />letter indicab'ng income tax exempt status <br />Certificate of Good Standing from the Minnesota Secretary of State's Office <br />r~| A charter showing you are an affiliate of a parent nonprofit organization <br />1 I Proof previously submitted and on file with the Gambling Control Board <br />Gambling Pramises Information <br />Name of premises where gambling activity wil be conducted (fo^ffies, list the site where the drawing will take place) <br />State/Zp CMeAddress (do not use Pp bo)0 m.County <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />P. 0CP3 <br />Ch&k the box or biCh%ck box or boxes^t indicate the type of gambling 'activity your organization will be conducting: <br />^JrffafftesiI i ’Bingo taffies (cash prizes may not exceed $12,000) I I ’Paddlewheels [~~| ’Pul-Tabs r~|*Tlpbeafds <br />’Equipment for these activities must be obta‘x:ed from a Icensed distributor. <br />This form will be made available In <br />alternative format (i.a. 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 lavdul gambing activities in <br />Minnesota. You have the right to refuse to <br />supply the infbnmatioh requested, however, <br />M 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 suppV <br />the informat'Bn requested, the Board wil <br />be able to process your appfcatlon. <br />Your name and and your organization's <br />name and address wil be public hfonrurtion <br />when received by the Board. Al the other <br />information that provide wil be private <br />data about you until foe Board issues your <br />permit. When the Board Issues your <br />permit, a!l of foe Information that you have <br />provided to the Board in foe process of <br />applying for your permit wM become pubi c. <br />If foe Board does not Issue you a permi, <br />all foe infonnaiion you have provided in foe <br />process of applying for a permit remsbis <br />private, with foe exception of your name <br />and yourorgantzation's name and address <br />wh'ich wl remain pubSc. <br />Private data about you are available only to <br />foe following: Board members, staff of foe <br />Board whose work assignment requiret <br />that they have access to foe information; <br />the Minnesota Department of Pubic Safety, <br />the Minnesota Attorney General: the <br />Minnesota Commissioners of <br />Administration, Finance, and Revenue; foe <br />Minnesota Legislative Auditor, national and <br />international gambing reguletofy agencies: <br />anyone pursuant to court order, other <br />individuate and agencies that are <br />specificaly authorized by state or federal <br />law to have access to the information: <br />indMduals and agencies for wh'ch law or <br />iegai order authorizes a new use or sharing <br />of tnfbrmation after this Notice was given; <br />and anyone wHh your consent