Agenda - Council - 08/25/2009 - Laserfiche WebLink

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LG24013 Application to Condurt Farr -h irlafl Rinne Page 2 of 2 �- IQ The information provided in thl 7ication is c plate and accurate to the best ofmy knowledge. Chief executive officer's signature Phone number -3 -71-�? Name ,(Please Date 6 .1.60*: fflt• o -00t 0Midoht Ac crtc �ivl> dgt (�t.arirf.�i}po i' v t:, :.:. it the gambling premises is within city limits, the city must sign this application. On beha/fofthe city/ approve this applfcailon for excluded bingo activity at the premises located within Print city name_ C', the city's jurisdiction. Signature of city personnel receiving application Title Er�- . c CX4-3 Lk— Dat 1 , It the gambling premises is located In a township, both tato county and township must sign this application, For the township: On beholf of the township, I acknowledge that the organization is applying for excluded bingo activihy within the township limits, Print township name A township has no statutory authority to approve or Signature of township official acknowledging application deny an 9pplication (Minn. Stat. 349.213, Subd. 2), Title For the county: On behalf of the county, i approve this application for excluded bingo activity at tt a Print county nares premises located within the county's jurisdiction. Signature of county personnel receiving application Title Date^ ...................... . ............ Send the application and proof of nonprofit status to: You will receive a document from the Gambling Control Board with Gambling Control Board your permit number for the gambling activity. Your organitation must keep its bingo records for 3-1/2 years, suite 300 South 1711 W. County Rd. 5 Roseville, MN 55113 Questions? Contact the Gambling Control Board at 551-639-4000. Ck, you may fax it to 511-539-4032. This form will be made available in alternative format (i.e. large print, Braille) upon request. Data Privacy Notice: The inrormatfon requested on this form (and any attachment) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in IaYAUI gambling sctivifies in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to eupply this information, the Board may not be able fn determine your qual•,ftcations and, as a consequence, may refuse to issue you an authorization. iF you supply rho Information requested, the Board will be able W process your appfication. Your name and your organ6gon`s name and address will be public informafion when received by the Board. All tha other Information Will be private data until the Board issue3 your authorization and the information then becomes public, if the Board docs not sue you an authorization, all information provided remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you is available to: Board members, Board sbtff whoso work requires vases to the information; Minnesota's Department of Public Safety, Attorney General; Commissioners of Administration, Finance, and Revenue: Legislative Auditor, national and intemational gambling regulatory agencies; anyone purouant to court order; other individuals and agencies that are speciricaily authorized by state orfederal law to have access to the Information: individuals and agencies for which taw or legal crdtN authorizes a now use or sharing of Information after this Notico Was given; and anyone with your consent.