HomeMy WebLinkAbout[04c] Gambling Application�A Council Agenda Item 4c
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MEETING DATE: March 18, 2010
AGENDA ITEM: Gambling Application — Accept the Application for Exempt Permit for the
Church of St. Joseph for an event to be held on July 3 and 4, 2010.
SUBMITTED BY: Administration
PREVIOUS COUNCIL ACTION: None
ATTACHMENTS:
Application for Exempt Permit .... ............................... 1 -2
REQUESTED COUNCIL ACTION: Gambling Application — Accept the Application for Exempt
Permit for the Church of St. Joseph for an event to be held on July 3 and 4, 2010.
Minnesota Lawful Gamblina
Page 1 of 2 06/03
LG220 Application for Exempt Permit Fee $50
For Board Use n y
Fee Paid
Check No.
Organization Information
Organization name Previous lawful gambling exemption number
Church of Saint Joseph .7 D
Street (mailing address)
City
State /zip code
County
12 W Minnesota Street
St. Joseph
IMN 56374
Stearns
Name of chief executive officer (CEO)
Daytime phone number of CEO
First name Last name
Include area code
Fr. Joseph Feders OSB
(320) 363 -7505
Name of treasurer
Daytime phone number of
First name Last name
treasurer. Include area code
Kevin Kluesner'
(320)363 -7505
Type of Nonprofit Organization
Check the item that best describes your organization:
_ Fraternal X Religious
Veteran _ Other nonprofit organization
Check the Item that indicates the type of proof your organization attached to this application:
_ IRS letter indicating income tax exempt status (501 c designation)
_ Certificate of Good Standing_ from the Minnesota Secretary of State's Office (must be current
_ A chanter showing you are an .affiliate of a parent nonprofit organization
,/Proof previously submitted and on file with the Gambling Control Board
✓ Catholic Directory
Gambling Premises Information
Name of premises where gambling activity will be conducted (for raffles, list the site where the drawing will take place)
Church of Saint Joseph.
Address (do"not use PO box)
Cky
Stete/zipcode
County
12 W Minnesota St.
St. Joseph
MN. 56374.
Stearns
Date(s) of activity (for raffles, indicate the date of the drawing)
July 3 and 4, 2010 Raffle drawing July 4, 2010
Check the items) that indicate the type of gambling activity your organization will be conducting:
X 'Bingo X Raffles (cash prizes may not exceed $12,000) _I 'Paddiewheels .X_ Tull-tabs _ `npboards
"Equipment for these activities must be obtained from licensed distributor.
Thisform will be made available in
alternative format (i.e. large print; Braille)
upon request. The information requested
on this form.(and any attachments) will be
used by the Gambling Control Board
(Board) to determine your qualifications to
be involved in lawful gambling aczivities In
Minnesota. You have the right to refuse to
supply the_ information requested; however,
if you refuse to supply this information, the
Board may not be able to determine your
qualifications and, as a consequence, may
refuse to issue you a permit. If you supply
the information requested, the Board will
be able to process your application.
Your name and and your organization's
name and address will be public
Information when received by the Board.
All the other information that you provide
will be private data about you until time
Board Issues your permit. When the Board
issues your permit, all of the information
that you have provided to the Board in the
process of applying for your permit will
become public. If the Board does not issue
you a permit, all the information you have
provided in the process of applying for a
permit remains private, with the exception
of your name and your organization's name
and address which will remain public.
Private data about you are available only to
the following: Board members, staff of the
mara wrmose worn assignment requires
that they have access to the Information;
the Minnesota Department of Public
Safety; the Minnesota Attomey General;
the Minnesota Commissioners of
Administration, Finance, and Revenue, the
Minnesota Legislative Auditor, national and
international gambling regulatory agencies;
anyone pursuant to court order; other
Individuals and agencies that are .
specifically authorized by slate or federal
law to have access to the information;
individuals and agencies for which law or
legal order authorizes a new use or sharing
of information after this Notice was given;
and anyone with your consent.
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LG220 Application for Exempt Permit
Organization Name Church of Saint Joseph
Local Unit of Government Acknowledgment
If the gambling premises is within city limits, the
city must sign this application.
On behalf of the city, I acknowledge this application.
Check the action that
the city is taking on this application.
The city approves the application with no
waiting period.
❑The city approves the application with a 30 day
waiting period, and allows the Board to issue a
permit after 30 days (60 days for a first class
city).
The city denies the application.
Print name of city.
(Signature of city personnel receiving application)
Title
Date
Page 2 of 2
06/03
If the gambling premises is located in a township, both
the county and township must sign this application.
On behalf of the county, I acknowledge this application.
Check the action that
the county is taking on this application.
The county approves the application with no
waiting period.
The county approves the application with a 30 day
waiting period, and allows the Board to issue a
permit after 30 days.
The county denies the application.
Print name of county
(Signature of county personnel receiving application)
Idle
Date.
TOWNSHIP: On behalf of the township, I acknowledge that
the organization is applying for exempted-gambling activity
within the township limits. [Atownship 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 � i4L complete and and accurate to the best of my knowledge.
Chief executive officer's signature /, : 0;3-4
Name (please print) Fr. Joseph F e d e r s, O S B Date_/
Mail Application and Attachments
At least 45 days prior to your scheduled activity date send:
• the completed application,
• a copy of your proof of nonprofit status, and
• a check for $50. 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
Roseville, MN 55113
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