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LG240B Application to Conduct Excluded Bingo
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<br />CHIEF EXECUTIVE OFFICER-'S SIGNATURE ,,i ;
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<br />The Information provided In this applIca on is complet d accurate the best of my knowledge.
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<br />Chief executive officer's signature /'� I /" U//y
<br />Date
<br />Print name Deacon Randy Bauer
<br />LOC AL UNIT. OF G'OVERNMEjVT ACKNOWLEDGMENT'
<br />CITY APPROVAL
<br />for a gambling premises
<br />located within city limits
<br />On behalf of the city, I approve this application for excluded
<br />bingo activity at the premises located within the city's
<br />jurisdiction.
<br />Print city name e' ' ' y c f Ps.._.rti
<br />COUNTY APPROVAL
<br />for a gambling premises
<br />located in a township
<br />On behalf of the county, I approve this application for excluded
<br />bingo activity at the premises located within the county's
<br />jurisdiction.
<br />Print county name
<br />Signature of city personnel )•
<br />Signature of county personnel
<br />Title 1f ^r-AeR., Date 3 f 2---�1 / Y
<br />Title Date
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<br />'TOWNSHIP - If required by the approving co4ty.
<br />On behalf of the township, I acknowledge that the ok anization
<br />is applying for excluded bingo activity within the township limits.
<br />[A township has no statutory authority to approve or ddgy
<br />an application, per Minnesota Statutes 349.166, Subd 2.]'
<br />Print township name
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<br />Signature of township officer
<br />Title Date
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<br />Mp►5rL APPL�CATIO'N q D ATTACII�!IT.,
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<br />Fax the application and a copy of your proof of
<br />nonprofit status to (651) 639-4032 or mall to:
<br />Gambling Control Board
<br />1711 West County Road B, Suite 300 South
<br />Roseville, MN 55113
<br />You will receive a document from the Gambling Control Board
<br />with your excluded permit number for the bingo activity.
<br />Your organization must keep Its bingo records for 3-1/2 years.
<br />Questions?
<br />.Call the Licensing Section of the Gambling Control
<br />Board at 651-539-1900,
<br />This form will be made available in alternative format (i.e. large print, Braille)
<br />upon request.
<br />Data privacy notice; The information requested on this Ail other Information provided will be pri- General; Commissioners of Administration,
<br />form (and any attachments) will be used by the Gambling vate.data about your organization until the Minnesota Management & Budget, and
<br />Control Board (Board) to determine your organization's Board Issues the permit. When the Board Revenue; Legislative Auditor, national and
<br />qualifications to be Involved In lawful gambling activities in Issues the permit, all Information provided International gambling regulatory agencies;
<br />Minnesota. Your organization has the right to refuse to will become public. If the Board does not anyone pursuant to court order; other Indi-
<br />supply the information; however, if your organization Issue a permit, all Information provided vlduals and agencies speciflcally authorized
<br />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
<br />able to determine your organization's qualifications and, organization's name and address which will the Information; Individuals and agencies
<br />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
<br />organization supplies the Information requested, the Board organization are available to; Board mem- new use or sharing of Information after this
<br />will be able to process the application. Your organization's bers, Board staff whose work requires notice was given; and anyone with your
<br />name and address will be public Information when received access to the information; Minnesota's written consent.,
<br />by the Board. Department of Public Safety; Attorney
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