Agenda - Council - 03/22/2011 - Laserfiche WebLink

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Page 2 of 2 LG240B Application to Conduct Excluded Bingo 3/11 Chief Executive Officer's Signature The information provided in this applic Lion i complet Chief executive officers signatur & an ' urate to the best of my knowledge. Phone number 651-291-4415 Name (please print) Deacon Randy Baue Date 3/10/1 1 Local Unit of Government Acknowledgment and Approval If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I approve this application excluded bingo activity at the premises located the city's jurisdiction. for L, �m�} Print city name o� within CJ c ti_ ti� Signature of city personnel receiving application �p ('"° it�'� cr2 D; � 3/4 -6 k Title Date If the gambling premises is located in a township, only the county is required to sign this application. For the county: On behalf of the county, I approve this application for excluded bingo activity at the premises located within the county's jurisdiction. Print county name Signature of county personnel receiving application Title Date For the township: On behalf of the township, 1 acknowledge that the organization is applying excluded bingo activity within the township limits. A township has no statutory authority to approve deny an application (Minn. Stat. 349.166, Subd. 2). (Township signature is not required) for Print township name or Signature of township official acknowledging application Title Date Mail Application and Attachment pp (s) Pent dorm Send the application and proof of nonprofit status to: Gambling Control Board Suite 300 South 1711 W. County Rd. B Roseville, MN 55113 Or, you may fax it to 651-639-4032. You will receive a document from the Gambling Control Board with your excluded permit number for the gambling activity. Your organization must keep its bingo records for 3-1/2 years. Questions? Contact the Gambling Control Board at 651-639-4000. This form will be made available in alternative format (i a large print, Braille) upon request. R' eSet ��rnl Data privacy notice: The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your organization's qualifications to be involved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the information; however, if your organization refuses to supply this information, the Board may not be able to determine your organization's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the information requested, the Board will be able to process your organization's application. Your organization's name and address will be public information when received by the Board. All other information provided will be private data about your organization until the Board issues the permit. When the Board issues the permit, all information provided will become public. If the Board does not issue a permit, all information provided remains private, with the exception of your organization's name and address which will remain public. Private data about your organization are available to: Board members, Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies specifically authorized by state 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 written consent.