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NCU-26-2001 10:18 <br />*■. m <br />GAMBLING CONTROL BOARD <br />Minnesota Lawful Gambling <br />LG220 - Application for Exempt Permit <br />6516394073 <br />Pag« 1 of 2 <br />P.01^02 <br />2IQ^ <br />Fee - $25 <br />Organization Information <br />For ftoard lise unly <br />Fee Paid <br />Organization name <br />/7^rvu/^ Zr=MtL <br />Previous lawftjt gambling yem ption numbar__[ <br />Name of chief executive officer (CEO) <br />First name Last name <br />^37*?^Name of treasurer <br />Fir^ name <br />C^KkLl <br />Type of Nonprofit Organization <br />K\t^^ L. <br />Last name <br />Llhri-h> <br />Daytime phone number of CEO <br />95A"'^T/-366/ <br />/l/N <br />Check the box that best describes your organization: <br />□ Fraternal □ ^igious <br />f~| Veteran O-^ttier nonprofit organization <br />Check the box that indicates the type of proof your organization attached to this applicatiirj: <br />n IRS letter Indicating income tax exempt status <br />[ I Certificate of Good Standing from the Minnesota Secretary of State's Office <br />PI ^efiarter showing you are an affiliate of a parent nonprofit organization <br />previously submitted and on file with the Gambling Control Board <br />tName o7 praises where gamblng activity wM be conducted (for raffleyist the site where tl^rawing will take place) <br />Address (do not use PO box) <br />GlJ> <br />City 0 State/Zip Code County <br />a) <br />Date(s) of activity (for ftffles, indcate the ( <br />. ^U^\pAU <br />Check the box or boxeslngl Iridicale the i <br />Q •Bingo (cash pnzes i <br />date of the drawing) i <br />kHhA¥^( J <br />type of gar. j^ngy6ctivfty your organization will be conducting: <br />nay not exceed $12,000) f~~l *Paddlewhee!s □‘PuHabs □'Tipboards <br />btalned ffom a ficensed dbtifoutor. <br />_____ u«nr orn,nJ,*««n-* WefoUowing: Board members. staHorme <br />alternative formet O-e* iarfl® Phnt. BraJM tfiat aw» tePthc intermation; <br />upon request The Informailon requc^ SeEesota Deparlmcnt of Pubic Safety, <br />cn this form (and any attachments) wiB b« infofmation that ,he Minnesota Attorney General: the <br />used by the Gambling Control Board Minnesota Commissioners of <br />(Board) to determine your quaRficatxms to «** hau« Administration. Finance, and Revenue; the <br />tTe''lI^voW^’la^Tg^ Mhnesota Legisladv* Auditor, natjonaland <br />Board maVnot’be able to aetermine your aB the information you haveprovided in the <br />Minnesota. You have the right to refuse to J® international gamblng regulatory agencies;supply the information requested; however, applying for your permrtwil become pobBc. w <br />If you refuse to supply this foiormalion. the If the Board does not issue you a petmit.anyone pursuant to court order; other <br />individuals and agencies that are <br />process of applying for a peimit remains »P««tariiy authonzed by state orfedar^ <br />_ _ ^ _ pnvalc, with the exception of your name <br />the information requested, the Board will address authorfees a new use or sharing <br />quarrfications and. as a consequence, may law to havo access to the information; <br />refuse to Issue you a perm«._ If you WPPV individuals and agencies tor which |aw or <br />be able to process your app&pqiicn.rour app81pq|i<which wil remain public. <br />PrtvBte data about you are available only to of information after this Notice was given; <br />and anyone with your consent