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MRy-20-2003 14:29 GPH6LING COITROL BQRRD C>51S394e73 P.02/09 <br />Minnesota Lawful OambUng <br />L6220 - Application for Exempt Permit Fae-$25 <br />Oroanintion Infpmiationumangai <br />ppj» 1 of a Mi <br />rui¥TiiiUwUi» <br />TC»Cu>B5Pg5S6BaM«wplanm^ <br />Gtrad <br />7vS 5^Vvcf*.l<c\j~T}r' <br />Or L^iLjc\f <br />Cly <br />tc, <br />StataOtpCoda <br />Nam* of chief easouOve offlow (CEO) <br />FMiwma <br />S <br />Laatnam* <br />FMnama Laetnonte J <br />l6p Nr <br />Dqiaw phone numbar of CEO <br />■5'5'2 -^7t-S10'» <br />DaitnM phono number Of <br />TVpa of Nonprofit dpoanizalion <br />Chock th# box that beat describee pouro/gartraton; <br />Ol Fratamal O R^ioua <br />r~l Veteran Q3 Other nonprofit organbatlon <br />Check the box (hat kidteatoa the type of proof your ofyaniz^ion a^^^chod to Ml appfcaBon; <br />IRS letter indicating income tax exempt status <br />leftfficate of Good Standing from the Minnesota Secratary of State's <br />P) A charter ahowing you are an afliato of a parent nonprofit organbabon <br />Q Proof pravioualyaubmttod and on fie wth the Oambing Control Board <br />• .nr' <br />Cambling Premlo— Infonroition <br />N«ii*orpreinlMSMihereoAfflbbtgaGMy«rtibeeondiioM(toriHnee.MthealowheraaMdfmaigwftaMplMe) <br />_______Ac _____________ <br />AMreu (do not mo PO bo>0 Slaia/ZOCode County <br />Oali(s) of acMy (br lalllse, Micati th* delB of the drearltg) <br />Check bieiKU Or boxes'l^lndlcatiiftoiype of oamfalngactMy your oigaibaaMwabooonduding: <br />[£] •Bhao ^ Rentes (ceihpiteesmoy not exceed $12,000) Q •Peddteeheeli □*Pul-Tebe □*TMda»dd <br />»yir^r«Mnttbfeies*eclMaesmuabeoM»inedeomafcenseddb«t>eor, <br />Thie form wm be mad* avaOabI* in <br />tekimmtifi Ibnnet 0-c. las* print, BraBs) <br />upon request Thai iomiaOoniequaelsil <br />on tite bim (and any altechiiiems) wl be <br />used'by the Oambllng Control Board <br />(Boeni) to datatiNne yourquaMcettons to <br />be Imotired In tewftil gembbie acMbee in <br />Mlnriesole. You hew #t* right to refUeetr <br />supply tie tetormebon requested; however, <br />t you retos* to iuppty this totermeOon. the <br />Bored may not be able to detenntoe your <br />qiMMlBOBoni reid. 00 a oonaaquonce, <br />retoeetoliyyouopen^Jtgu^p^ <br />Oie taAvinretoit teuuilted. tie Board wB <br />be <br />Your name and and your organteaeonTs <br />name and addresa wf be pubiB IdonnalDn <br />whan received by trie Board. Altteotoar <br />intonnalion (hat you prodde wB be prtorie <br />data about you unfl tie Board kajan your <br />perme. Whan the Board Issuea your <br />pamill, al of the totoimation that yiNi hawa <br />provldad to the Board to lha prooeas of <br />appiytog ter your premtwB become pubiB. <br />t tie Bored doaa not bau* you a premk, <br />dItoe totormaOon you haw provldad to tw <br />piooasa of epplytog tor a permt rotnatoa <br />private, wih (ha exeapton of your name <br />and your organBathxTa name and addraaa <br />which wB lamato puMo. <br />metoiBweig: Boartniambara.aiaBdflie <br />treMmaaotaDapatbnantofPutilBlIBtBr. <br />the Wtoneaola Allomey Oanerak the <br />Minnaaota Cemmissionere of <br />AdmtoMraUon. Ftoreioa, and Rewnuo; tie <br />totematonai ganMitg leButotory aganciaa; <br />anyona puriuant to court oidar, other <br />indMduala and agendea Biat areapacBealy auttKxtaad by state or toderai <br />tow to haw aoota* to the totarvnaHon <br />todteUualaam <br />tegalredaraul <br />or aitormeloii <br />and agandaa ter which tew or <br />autooreea a new ua* or dMttoa <br />tMaNcBDewaagMBn: