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LG230 Application to Conduct Off-site Gambling 5/13 Page 2 of 2 <br />Acknowledgment by Local Unit of Government: Approval by Resolution <br />CITY APPROVAL for a gambling premises COUNTY APPROVAL for a gambling premises <br />located within city limits. located in a township <br />City name County name <br />Date approved by city council Date approved by county board <br />Resolution number (if none, provide meeting minutes) Resolution number (if none, provide meeting minutes) <br />Signature of city personnel Signature of county personnel <br />Title Date Signed Title Date Signed <br />Chief Executive Officer [CEO] Acknowledgment <br />10. The person signing this application must be your organization's CEO and have their name on file with the <br />Gambling Control Board. If the CEO has changed and the current CEO has not filed a LG200B Organization <br />Officers Affidavit with the Gambling Control Board, he or she must do so at this time. <br />11. I have read this application, and all information is true, accurate, and complete, and if applicable, agree to the <br />lease terms as stated in t 's application. <br />CEO signature Date i 1 1O <br />12. Print CEO name Q Daytime phone 7k ' '" 65 <br />Mail or fax to: No attachments required. <br />Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />FAX: 651-639-4032 <br />This publication will be made available in alternative format(i.e. large print, Braille) upon request. <br />Data privacy notice: The information requested on this form provided will become public. If the Board does not issue a <br />and any attachments) will be used by the Gambling Control permit, all information provided remains private, with the <br />Board (Board)to determine your organization's qualifications exception of your organization's name and address which will <br />to be involved in lawful gambling activities in Minnesota. Your remain public. <br />organization has the right to refuse to supply the information; Private data about your organization are available to: <br />however, if your organization refuses to supply this information, Board members, Board staff whose work requires access to the <br />the Board may not be able to determine your organization's information; Minnesota's Department of Public Safety; Attorney <br />qualifications and, as a consequence, may refuse to issue a General; Commissioners of Administration, Minnesota Manage- <br />permit. If your organization supplies the information requested, ment&Budget, and Revenue; Legislative Auditor, national and <br />the Board will be able to process your organization's application. international gambling regulatory agencies; anyone pursuant <br />Your organization's name and address will be public information to court order; other individuals and agencies specifically <br />when received by the Board. All other information provided will <br />authorized by state or federal law to have access to the <br />information; individuals and agencies for which law or legalbeprivatedataaboutyourorganizationuntiltheBoardissues <br />order authorizes a new use or sharing of information after thisthepermit. When the Board issues the permit, all information <br />notice was given; and anyone with your written consent.