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<br />Minnesota Lawful Gambling <br /> <br />Page 1 of 2 <br /> <br />3/01 <br /> <br />LG220 Application for Exempt Permit Fee - $25 For Board Use O-nly <br /> Fee Paid <br /> <br />Organization Information Check No. <br />Organization name Previous lawful gambling exemption number <br />Hastings Fire Department Relief Association X-19043 <br />Street City StatelZip Code County <br />115 w. 5th Street Hastings MN 55033 Dakota <br />Name of chief executive officer (CEO) Daytime phone number of CEO <br />First name Last name <br />Michael D. Eggert 651-480-6150 <br />Name of treasurer Daytime phone n umber of <br />First name Last name treasurer: <br />James c. Gelhar 651-480-6150 <br />Type of Nonprofit Organization <br />Check the box that best describes your organization: <br />0 Fraternal 0 Religious <br />D Veteran IKXI Other nonprofit organization <br />Check the box that indicates the type of proof your organization attached to this application: <br />0 IRS letter indicating income tax exempt status <br />~ Certificate of Good Standing from the Minnesota Secretary of State's Office <br />D A charter showing you are an affiliate of a parent nonprofit organization <br />0 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 />Knights of Columbus Hall <br />Address (do not use PO box) City StateJZip Code County <br />Highway 61 South Hastings MN 55033 Dakota <br />Date(s) of activity (for raffles, indicate the date of the drawing) <br />9-14-03 <br />Check the box or boxes that indicate the type of gambUng activity your organization will be conducting: <br />D *Bingo ~ Raffles (cash prizes may not exceed $12,000) ~ *Paddlewheels IQg *Pull-Tabs WI *Tipboards <br />*Equipment for these actMties must be obtained from a licensed distributor. <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 quaHfications to <br />be involved in lawful gambling actMties 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 /> <br />Your name and and your organization's <br />name and address win be public Infonnation <br />when received by the Board. All the other <br />information that you provide will be private <br />data about you untO the Board issues your <br />permit. When the Board issues your <br />permit, aU of the information that you have <br />provided to the Board in the process of <br />applying for your permit wiD become public. <br />If the Board does not issue you a permit, <br />all the information you have provided in the <br />process of applying for a permit remains <br />private, with the exception of your name <br />and your organization's name and address <br />which will remain public. <br />Private data about you af9 available only to <br /> <br />the following: Board members, staff of the <br />Board whose work assignment requires <br />that they have access to the information; <br />the Minnesota Department of Public Safety; <br />the Minnesota Attorney General; the <br />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 />legal order authorizes a new use or sharing <br />of information after this Notice was given; <br />and anyone with your consent <br />