Agenda - Council - 10/28/2014 - Laserfiche WebLink

Home

LG240B Application to Conduct Excluded Bin The informatlon provided In this application s complete Chief executive officer's signature Print name 1Pacovt aZi:w �.e✓' tve -11 0 6/13 Page 2 of 2 CITY APPROVAL for a gambling premises located within city limits On behalf of the city, I approve this application for excluded bingo activity.at the premises located within the city's jurisdiction, Print city name (' ? "ri v E y-i Slgnature of city personnel Title l" rc e c D‘. Date to to thst of my knowledge, Date 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 Signature of county personnel 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 township has no statutory authority to approve ordeny an application, per Minnesota Statutes 349.166, Subd.2,) Print township name Signature of township officer Title Fax the application and a copy of your proof of nonprofit status to (651) 639.4032 or mall to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 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 tawful.gambling activities In Minnesota. Your organization has the right to refuse to supply the information; however, if your organization refuses to supply thls 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 informatlon requested, the Board will be able to process the application, Your organization's name.and address will be public Information when received by the Board. Date 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 at651-539-1900. This form will be made available In alternative format (i.e. large print, Braille) upon request. All other informatlon provided will be pri- vete data about your organization until the Board Issues the permit. When the Board Issues the permit, al) information provided will become public. If the Board does not Issue a permit, ail 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 mem- bers, 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 Indi- viduals 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,