Agenda - Council - 09/11/2012 - Laserfiche WebLink

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CHIEF EXECUTIVE OFFICER'S SIGNATURE The information Chief executive Print name provided in this applicatle complete aid .ccurat officer's signatur . _a y /�. to the be of y knowledge, 0 L._- ill _....r Date er Deacon Randy Bauer LOCAL UNIT OP GOVERNMENT ACKNOWLEDGMENT On behalf bingo activity jurisdiction, Print city Signature CITY APPROVAL for a gambling premises located within city limits of the city, I approve this application for excluded at the premises located within the city's name L_; 4 / nn COUNTY APPROVAL for a gambling premises located in a township 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 of city personnel Signature of county personnel Title .{-.I 0. ate 9 /5 h L Title Date TOWNSHIP - If required by the approving county. On behalf of the township, I acknowledge that the organization is applying for excluded bingo activity within the township limits, [A townshl has no statuto authorit to a approve or den p rY y pP y an application, per Minnesota Statutes 349,166, Subd 2 ,] Print township name gJf f; pi "' zt ' "1�Y �,4I zn hu , G iix d�1i� i�ii 1H�I +ii 3 a: r stF t , , , r , <� # Signature of township officer Title Date MAIL APPLICATYON AND ATTACHMENT Send the application and a copy of your proof nonprofit status to Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 ir is of J ,_... .wa::,f 9 d L e x' ' FOr :; � fo X40 t _ You will receive a document from the Gambling Control Board with your excluded permit number for the bingo activity, Your organization must keep Its bingo records for 3 -1/2 years, Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. This form will be made available In alternative format (I.e. large print, Braille) upon request,. Data privacy notice: The information requested on this All other Information provided will be prl- General; Commissioners of Administration, form (and any attachments) will be used by the Gambling vate data about your organization until the Minnesota Management & Budget, and Control Board (Board) to determine your organization's Board Issues the permit. When the Board Revenue; Legislative Auditor, national and qualifications to be Involved In lawful gambling activities In Issues the permit, all Information provided International gambling regulatory agencies; Minnesota. Your organization has the right to refuse to will become public, If the Board does not anyone pursuant to court order; other Indl- supply the Information; however, If your organization Issue a permit, all Information provided vlduals and agencies specifically authorized refuses to supply this Information, the Board may not be remains private, with the exception of your by state or federal law to have access to able to determine your organization's qualifications and, organization's na me and address which will the information; individuals and agencies as a consequence, may refuse to Issue a permit, If your remain public, Private data about your for which law or legal order authorizes a organization supplies the Information requested, the Board organization are available to: Board mem- new use or sharing of Information after this will be able to process the application, Your organization's bers, Board staff whose work requires notice was given; and anyone with your name and address will be public Information when received access to the Information; Minnesota's written consent, by the Board, Department of Public Safety; Attorney LG240B Application to Conduct Excluded Bingo 6/12 Page 2 of 2