Agenda - Council - 08/26/2008 - Laserfiche WebLink

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AUll. LV. LVU~ 11: 1 YAM rlKtSIONt MtlAL ~WUUCIS, LLC NU.LY~/ ~. Jl4 LG240B Application to Conduct Excluded Bingo Page 2. of 2 11/04 Organization name Chief Executive Officer's Signature The ~.~eg "'.1hI~'"f".cation is """,'ete.nd eocu"," to tho b~l of tny knowledge- , . . . Signature~ ~~~ Daytime phone nu,!,~er !~3 ilf:Ll-o ~ / Name (ple;'e print) ]::)...'2_6 ' ~ VL"~~ Date4r~J '08 Local Unit of Governm,ent Acknowledgment and Approval Ifthe gambling premi$es Is-within city limits. the city must sign this application. 00 behalf of the city, I hereby approve this C. ' \.- o{:- ~ .....\-4 application for excluded bingo activity at the P" t n I. {f "ti. /) ~ r premises located within the city's jurisdiction. nn~ame CI -r--: \. ~ \.., , .......-...... Signature of city personnel receiving application Title 'F:-~. ~.~ DateR-~ If the gambling premi$es Is located In a townShIp, both the county and township must sign this application. Forthe townshiD: On behalf of the township, I ackl'lowledge that the organization is applying for axcluded bingo actiVity within the township limits. Print name of township A township has no statutory authority to approve or deny an application (Minnesota statute 349213, subd. 2)" Signature of township official acknowledging application Title Date---1 1_ for the cot4nty: On behalf of the county, I hereby approve this application for excluded bingo activity at the premises located within the county's jurisdiction. Print name of county. (Signature of ~ounty personnel receiving appiication) Title Date~---1_ Mail application and attachment(s) Send the completed application and a copy of your proof of nonprofit status (see instructions) at least 30 days prior to the aclivity date to: Gambling Ctmtrol Board Suite 300 South 1711 W. Cotlnty Rd. B RoseviJJe. MN 55113 Thisiorm will be made available in a1temalivefonnatQ.e"laJge ptIn~ Brame) upon request. The Information requested on this form (and any . anaooments) wID be. used by the Gambling Control Board (Board) to determine yourquelli6catlons to be involved in lawful gambling aCllvllles in JVliMesota. YOl.! have the rightto raliJoo to suppl)' the infcrmalion requested; however, if you refuse to supply this information. the Board may not be able to determine yourquallfications and. as a consequence, may refuse to iesue you an authorization. If you supply the Infom1alion requested. the Board will be able to process your application. Your nsme and your organimion's name and address will ~ publi~ information wilen received by the Board. All the olherinformaliontl1atyou provide will be private data abovt you until the Board issues your autnorl%ation. When the Soard Issues your autho~t1on. aU of the information that yoo have provided to the Board in the process of applying for your author1zation wnl become publi~ If the Board dOBe not Issue you an authorization. all the information you haVG provided In the process of applying for an authorization remains private, with the exception of your name and your organ~lion'$ name and address which wiU remain public. Private dllla about you are aveilable only to ihe fo~owlng: Soero members. slalfcfthe Board whose workassignmantrequires that they have aCOE!66 to the Information; the Minnesota Oepartmant of Public Safety; the Minnesota Attorney General; the Minnesota CommissIoners of Administratlon. Finance, and Revenue; the Mlnnesola LaglslativeAudilor, nEl!ional and international gambling regula10ry agencies: anyone pursuant \0 oourtorder; olt1e( Incflliidual5 snd agencies tl1atare specilicaUyaulholtzed by slate orfederal1awto have ac:cess to th~ Infonnation; indlvlduale and ageneiasforwhich law orlegal orderaulhorites a new use or e;harlng of information aftarthls Notice was given; and anyone with ~ur consent. -17-