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LG240B Application to Conduct Excluded Bingo <br />Page 2 of 2 <br />6/07 <br />.:..................... .::.......... •......:::::::::::::::::::::::::::::.,..,..:::::::::.;......:.:.......................;.........................................................::::......; ................;........,,. <br />WGhAd xecu h:e`. idse('�S:.}1..tl <br />........... .... ......... <br />The information provided in thiC lication is co plate and accurate to the best of my knowledge. <br />2(a <br />Chief executive officer's signature Phone number <br />6 <br />Name (please print) 56 Date �r3�Q. <br />Lb l al p of Cy.�y �trr ...... A'A d t d r t n#:ar►d ���.......M a::::..: ' ° = : ' <br />If the gambling premises is within city limits, the city must sign this application. <br />c n <br />On behalf of the city, I approve this application for Print name <br />city <br />excluded bingo activity at the premises located within <br />the city's jurisdiction. <br />Signatures of city personnel receiving applications <br />Title CU4d-fDate a/ <br />If the gambling premises Is located in a township, both the county and township must sign this application. <br />For the township: On behalf of the township, <br />I acknowledge that the organization is applying for <br />Print township name <br />excluded bingo activity within the township limits. <br />A township has no statutory authority to approve or Signature of township official acknowledging application <br />deny an application (Minn. Stat. 349.213, Subd. 2). <br />Title Date I I <br />For the county: On behalf of the county/ approve Print county name <br />this application for excluded bingo activity at the <br />premises located within the county's jurisdiction. <br />Signature of county personnel receiving application <br />Title Date / I <br />:::::.....::::::.a_.............................."::'."::::::::::::::':::;:::............................... ................ ,...........................,..;.;..;....:.;.....................;. <br />M4H A Ilcati�n An Attachln�ttit s <br />........................................................ . (.:...............::.::::.:. <br />Send the application and proof of nonprofit <br />You will receive a document from the Gambling Control Board with <br />status to: <br />your permit number for the gambling activity. Your organization must <br />Gambling Control Board <br />keep its bingo records for 31/2 years. <br />Suite 300 South <br />1711 W. County Rd. B <br />Questions? Contact the Gambling Control Board at 651-639-4000. <br />Roseville, MN 55113 <br />This form will be made available in altemative format (i.e. large print, <br />Or, you may fax It to 651-639-4032. <br />Braille) upon request. <br />Data Privacy Notice: The information requested on this form <br />(and any attachments) will be used by the Gambling Control Board <br />(Board) to determine your qualifications to be irrvolved in lawful <br />gambling activities in Minnesota. You have the right to refuse to <br />supply the information requested; however, if you refuse to supply <br />this information, the Board may not be able to determine your <br />qualifications and, as a consequence, may refuse to issue you <br />an authorization. If you supply the information requested, the <br />Board will be able to process your application. <br />Your name and your organization's name and address will be <br />public information when received by the Board. All the other <br />information will be private data until the Board issues your <br />authorization and the information then becomes public. If the <br />Board does not issue you an authorization, all information provided <br />remains private, with the exception of your name and your <br />organization's name and address which will remain public. <br />Private data about you is available to: Board members, Board staff <br />whose work requires access to the information; Minnesota's <br />Department of Public Safety, Attorney General; Commissioners of <br />Administration, Finance, and Revenue; Legislative Auditor, national <br />and international gambling regulatory agencies; anyone pursuant to <br />court order, other individuals and agencies that are specifically <br />authorized by state or federal law to have access to the information; <br />individuals and agencies for which law or legal order authorizes a <br />new use or sharing of information after this Notice was given; and <br />anyone with your consent. <br />ZS— <br />