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1a Gambling Permit/St. Hubert '.1 _ ~~- ¡ " . . ' ,- . _:;.:".',¿"'f,:~ ':' __ .' __ _' _;'_ ," ,", _ ,_:, __ _ .- ' "M1;,nesofåLawfùIGambling ," " " "~þp.iéátitJhfor ExempfPärmit ~ ""&2%0 " " 0,' ån~tiorilnforination . '," ,"..,.,.-,' ,.,," -. -' -, .' , o~lÌo)IIname ", ..' ,,,, -"'F - Pagè 1 of 2 F IIo8rð U. 'On 10198 F~ Psi«!. Chèck No~ ;::;.,,;(,,"" Inmills . ~": R " '---1-".1. ,Previous laWful gambling eXellÌptlpn number -1,(;)~OI .', touiitY , " : city Ð T"" " ~ ofchlèfexêC;utivà~ (CEO} oforganlìátion ~ ~!;~~-P~Ö\~f¿ ~",\-làstriàmè'Á ,'U, Name of teasurer m organization 1.< ", " " ALZ~~N l~', \£ ~strÂmkt: Typè of NOÌ1prôflt OrgàtiiÜ~o~ ' , " " Chéck the box ~r :ra~e:èribèS ÝOU~:;:::~ q Vètèmn'" 'D'Oth~rnònp.ufitð¡g~Ì1fiàb·oh;' ,', Check the ooJé thàt Indiœtes the type c>tproofyour ¡;fb~n1iàti6~~tfåbrièd tq'ttíis application: o IRS letter indiêáting income tax exempt status '0 Certificate of Good Stàndlng from the Minnesota Secretary of State's Office o /A charter showing y¡)U a~ an,affiiiate ofa parent nonprofit organization uf Proof previously submltteçl and'on file with the Gambling Control Board " Daytime þhone number of " treasurer: (- VJ...) 0/3 l{ fjlò ',~ - -.-- -' ,-"'~'-- D..?tE'ls) of activity (for rallies, indicate the date of the drawing) 1 ...._ . ~J.~: Check the box or boxes that i icate Ìhe typ;di gambling activity your organizatioò will be conducting: " ,O·Bingo ~aflles , 0 'Paddlewheels O'Pull-Tabs 0 *Tipboards "EquIpment for these activities must be obtained from a ncensed distnbulor. , This form will be made available in alternative Your name and J\I1d your orD!I1izatiorì's namePñvaIe d8ta abOut you are avaiIabie only 10 the íOnnà! [r.e.1aIge print. ~r.iIè) upon request. the and address wi!! þe pubBc informat1Qn when fqIIowing, Board members, stall oUhe BoMI information Jl!quésted on this form (atldany receNed by the Board, AI the other information /Wflosework assignmerl!;rØquies ll)at'theyhave aIIachmentil) will be used by the Gàmb6ng that you pmvide v.iII be private data about you access 10' the 'information; the Mi'nnesota Control Board (Board) 10 determine Your unti the Boàrd issues your pennit. ,When the Deparllilenl of pubnc, ~ the Minnesota quafificatior$ 10 be ïnvolved in iI!WfuI garÚbling Board Issues your permit, II of the information A\lDmeyGenera/; the Minnesota CoI)¡rntssi9nerI acfI\rities ill ~ You haw the right to that you haw provided to the Board in the 'of AifminiSlrallon, FliIance,and ~Vei1ùe; the refuse to. supply the information ,requ~; process of applyingforyourpennhillbècóme , Minriesota Legislative Au~itor, nátional~nd ho-.ifyourefuselosupplylhismfonœtion.public. IftheBoMl~notrssueyouapennit" iri~mational g;¡mbDng regulatory agenCieS; the Board may nol be able 1IÍ determine your .. the informálfon you haVe provided In the ' anyone pursuantlo courtcrder. other ii!lMdùals quaibllónsand, as a èmsequenœ,lIIáyrefuse pn>cess of appIyiIg for a permitremains prIvaIe" ,arid agencies that are speclftcaUy aII1hOOzed by to ¡ssu~ you a penni\. If you supply thè with the ~xception of your name end your state, or federal laY( t6 have ;¡ocessto,\be Information requested, the Board will be able to organizatiÓl1's name and address which will infonnalion; indIVIduals and agencies fòf vmich process your apprtealion.. remain public. law or lègal order authOrizes a, new use or " shañR9 ofinformalion aftiIrthiSN0tic8 was given; and anyone with your consent. ''',', " ,~¡ ,':;~~:;> ^{\:,c,!f~,,~>; f~7>i)};;:~~'i~~:~~ ' 1" "~~" ) ~",.;O"" ..:_,,~ ..:~~:é:< '~f1~::~,:~' ,,-" ::; '''" ,,,7ë·Vi i ~<~~?-,,(~, I e ·.,~.<,,·,:.c""'~'·.~A"-. ~.~>:"::f?:~:;~,~~,~t~,!:,,~,.,,.~ ,.," :~f;:}(':Y'e:;~';"" ," .<", ::,,:, . l1Iämf¡ti~~lJr:·' .' :i,~;·, "'«~:q. ',::Î'.:dS}i:,_¡t..:.t:~, . '·.\Jmul~.ÐJt! ..,,-.. ',;;:,~,;'::'~\:' ~,;-." ....,- """ ., ',' '--'<~+~~:Jt:¡r,t,,_:"~,;+",.{·.'~,",;_,,}~~,:i .'M EM: 'OD ':';''''', " niA, " ,", ' ",',"'" ,,'._ .-,"e "", /-'",i,,' , " " ,';: ',--:/ -<f:,':;A.:,i·---':{?<',\,,"'~(~,,-~_; ¡~__ 'ArW"t~,),i;?y""d - :-. ,'.--- ,', ',C-- C:":.1'·"!'="-' __,' - ) CÎb'a;tti"t:cli.t"i>OitJižw¡,^ ; " - >~-,:~~..~,; ~'- - '~/ ',c.:..;. -- i~', '.~' ", y..,.;·.~f< "~,,' ^", b:":"~. ,", " ~ :(~._~;:~'.t;":'",''':''~';,~~:;':,:i',¡,\:,~,~ ':;<,' .¿ '" <' ' "", ~~;;;:'f4ij3Î7::'" :,,~: Karen Engel~ oti~~~e;""~""":'" ~;-~/:~~:~;,'¡: ,", ), : Phon/6Ìi.'f}37.1!JIXJ , : ',~, ,.' It:, ': e ",e "'~ _>, ~~:, . i;mmdFtJX612M~'c1.'2n,::, F~OM; Carol DunsÒlore;Support-Servu~est&, '~'.., ,_ I' _" .>, (~';__::~,:'" .' - ,_?;J¡,;J; ;,1,7."_ ; ~..;.._ '...,,' :k~-.~ '.. '~'__':;""-,'i;¡"',r ~ginmÌpgF¢t6Izi3ÛÌ51 "''ÌjATE: ' , ~"j\'1< " !blic'&¡dy F:xidJ.U514 ;Feb':'låry 1] ;-2000 '\':' ,; :' , -- - -,'~ , ':., ",": ,-,."- "_": ., ", -'',¡:.'~~'~¿- "',~ ,-:--.". -' ",i' ::'~~'(~'~::~;Ä: ;.;::K: ,," ,:)~:;L: '-,'~,- '":-' Y':<~<" ~':,~ ,"''''''-;''''' :',',w\;-:",:.,',:,~),'j':':Á~:~--~'A';".~ti?'~:r-¡(S~5:";"~:.-:,":;/;:t, .-::~ <._,:',:,:":~~ì~:"-J'~: Y'e6 www.d.thaÌth4Jsn1.mn.us SUB]: G~bl~ng P~rrmt for St. Hl!bert sf,irt!t2!!~~~P!~u~w>;,~, '::',~i\ ¡C' "Oll/l!bhng·Ðates:~ A"rll'29¡-ZOO&&>~; 1!Øì'!O,'i'\,'"",,,\.,, - "":"~' '. c - - ,', - _ " - . > ." .'·:;)':'-'-'~'i ,"t':;¡ :"':·~:::<,¡ß-:'~t~t??r.--' : :,,__-~!,~'~,'{;;;:!~,\': .;,'. :" \ __ /;~\7,t:2,':~::i __ I,' ,-.-,-;,'--:, , . ." I have conducted lj.baGkgi9und'investigation on Father Stev~n;DonaId µIrick and Fatþer LaWrence RpJJert Blake 'to~:thé ab,Í¡ve periJJit.) havef()ù~4 ~o reco"fl,on ' thesepartit:s: " ., .,.. ,.,'" '.""-', i::-' ,·..,CQ:ms ',-.. ., " ,'> '-,', . City ofChanhllSstIJ. A !TVWint community with cltan lakes, atI4/itvschools. a choiminr downl<1wtt, thrivinr businesses, and btautifid Darks, A mat Dladmlivt, work, ¡lnd Ii"," ¡,. Page 2 of2 10198 Application for Exempt Permit - LG220 Organization Name ChtJR, "- o.f ~1> l.kl-. T Local Unit of Government Acknowledgment (Required by Statute) On behalf of the city, I acknowledge this applicátion and three options for the cl1y: 1. Approve the application: By taking no action, the city allows the Board to issue a permit after 30 days (60 days for a first class city). 2. Waive the above-noted waiting period: The city allows the Board to issue a permit before 30 days (60 days for a first class city). Docu- mentation attached. 3. Deny the application by passing a resolution within 30 days (60 days for a first class city), Plint name of city: (Signature of city personnel receiving application) Tille Date I I On behalf of the county. I acknowledge this application and three options for the county: 1. Approve the application: By taking no action, the county allows the Board to issue a permit after 30 days, 2. Waive the above-noted waiting period: The county allows the Board to issue a permit before 30 days. Documentation attached. 3. Deny the application by passing a resolution within 30 days. Prtnt name of county: (Signature of county personnel receiving application) Title Date I I On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. A township has no statutory authority to approve or deny an application (Minn. Stal sec. 349.213, subd, 2). Plint name of township: (Signature oftownship official acknowledging application) Tille Date I I Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge, Chief Executive Officer's signature Name (please print) Date I I Mail Application and Attachment(s) At least 45 days prior to your scheduled activity date send: · the completed application; · a copy of your proof of nonprofit status, and · a $25 application fee (make check payable to "State of Minnesota"). Application fees are not prorated, refundable, or transferable. Send to: Gambling Control Board - , 1711 Weit County Road B, Suite 300 South Rosevllle, MN 55113 If your application has not been acknowfedged by the local unit of govemment, do not send the appiication to the Gambling Control Board. , Minnesota Lawful Gambling Application for Exempt Permit - LG220 Organization Information ~name paga 1 of 2 For &0."' Use On 10198 Fee Paid Check No. Initials Reœived ---1-1. Previous lawful gambling exemption number -¡ODOI County CIty Ð T Name of chief executlv, officer (CEO) of organization A~ -p~~'" Ej last name 1ít ,~n"~ O\~ìt. ~ Name of teasW'er of organization 1.- F? ~me \,.A.""' ~st name L.4JJ1l~i\Jl- - ~ {Akt:. - e,q,.' ·.s. Type of Nonprofit Organization Check the box that !Jest describes you~rg,nization: o Fraternal lZI"Religious o Veteran 0 Other nonprofit organization Check the box that indicates the type of proof your organization attached to this application: o IRS letter indicating income tax exempt status o Certificate of Good Standing from the Minnesota Secretary of State's Office o /A charter showiÓg you are an affiliate of a parent nonprofit organization OÝ Proof previously submitted and on file with the Gambling Control Board w~ Daytime phone number of treasurer: ( ~i J..) c¡ '3 i/ 91ð ' Gambling Premises Infonnation Name of premi~ where gamb~ng activity wiU be condu~ (for raffle~/liS¡ Jhe site where ¡e drawing w' take Plac:e~ ' -I)I~ 1/\ l~~ ù(__ A '.' it Lr.(lt, ¡"v . r'- é!ìf Add (do not use PO) City State/Zip Code Cou _.~ Q~ ~ a~ty (for raffles, indica~~9of the drawing) ~. :;;,.- ~.. Check the box or boxes that i icate thè type 0 gambling activity your organization will be conducting: o "Bingo ~Rafßes o "PaddlewheeJs o "PulJ-Tabs O*Tipboards "Equipment for these activities must be obtained from a ficensed distributor. This form will be made available in altemative format [Le.1arge print, Braiße)upon request. The infonnation requested on this fonn (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambrmg activities in Mlnnesola. You have the right to refuse to supply the infonnation requested; however, if you refuse to supply this information, the Board may not be able to detem1ine your quaIiIications II1d, as a consequenœ, mayrefuse to issue you a permil If you supply the information requested, the Board will be able to process your ap¡.!Ìl.dtilnL Your name and and your orgll1ÎZBtiOn's name and address Will be public infonnation when received by the Board. All the other information that you provide Will be private data about you until the Board issues your pennit. When the Board issues your pennit, all of the information that you have provided to the Board in the process of BJpfying for your pennit will become public. If the Board does not issue you a panni!, aD the information you have provided in the process of applying forapermftremains private, with the exception of your name end your organization's name and address which will remain public. Private data about you are available only to the following: Board members, stall of the Board whose wolte assignment requires Ihat they have access to the information; the Minnesota Department of Pubfic Safety; the Minnesota AtIIImeyGeneral; the Mi1nesota Commissioners of Administration, Finance, and Revenue; Ihe M'mnesota Legislative Audftor, national and intemational gambling regulatory agencies; ~ pursuant to court order, olher individuals and agencies Ihat are specifically authorized by state or federal law to have access to the information; indMduals and agencies for v.11ich Jaw or legal order authorizes.a new use r' sharing of infonnation alter Ihis Notice was giv and anyone with your consent , Page 2 of2 10198 Application for Exempt Permit - LG220 Organization Name C /"¡)R t ~ 0 .f S~ ¡j¡J J,~ T Local Unit of Govemment Acknowledgment (Required by Statute) ". On behalf of the city, I acknowlédge this application and three options for the city: 1. Approve the application: By taking no action, the city allows the Board to issue a permit after 30 days (60 days for a first class city). 2. Waive the above-noted waiting period: The city allows the Board to issue a permit before 30 days (60 days for a first class city). Docu- mentation attached, 3. Deny the application by passing a resolution within 30 days (60 days for a first class city). Print name of city: (Signature of city personnel receiving application) Title Date-' , On behalf of the county, I acknowledge this application and three options for the county: 1. Approve the application: By taking no action, the county allows the Board to issue a permit after 30 days, 2. Waive the above-noted waiting period: The county allows the Board to issue a permit before 30 days, Documentation attached, 3. Deny the application by passing a resolution within 30 days. Print name of county: (Signature of county personnel receiving application) Title Date I , On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits, A township has no statutory authority to approve or deny an application (Minn. Stat. sec, 349.213, subd, 2), Print name of township: (Signature of township official acknowledging application) Title Date , , Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge. Chief Executive Officer's signature Name (please print) Date I , Mail Application and Attachment(s) At least 45 days prior to your scheduled activity date send: · the completed application; · a copy of your proof of nonprofit status, and · a $25 application fee (make check payable to "State of Minnesota"). Application fees are not prorated, refundable, or transferable, Send to: Gambling Control Board 1711 West County Road B, Suite 300 South Rosevllle, MN 55113 If your application has not been acknowledged by the local unit of govemment, do not send the application to the Gambling Control Board.