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LG23O Application to Conduct Off-Site Gambling 6/15 Page2 of 2 <br />Acknowledgment by Local Unit of Governmentl Approval by Resolution <br />CITY APPROVAL <br />for a gambling premises <br />located within city limits <br />COUNTY APPROVAL <br />for a gambling premises <br />located in a township <br />City Name L S <br />Date Approved by City Council <br />Resolution Number 2osb-O0 <br />(If none, attach meeting minutes.) <br />Signature of City Personnel: <br />b D <br />Title Date Signed: <br />Loca! unit of government <br />must sign. <br />County Name: <br />Date Approved by County Board <br />Resolution Number: <br />(If none, attach meeting minutes.) <br />Signature of County Personnel: <br />Title Date Signed <br />TOWNSHIP NAME <br />Print Township Name <br />Signature of Township Officer <br />Title Date Signed <br />Complete below only if required by the county. <br />On behalf of the township, I acknowledge that the organization is <br />applying to conduct gambling activity within the township limits. <br />(A township has no statutory authority to approve or deny an <br />application, per Minnesota Statutes 349.213, Subd. 2.) <br />CHIEF EXECUTM OFFICER (CEO) ACKNOWLEDGMENT <br />The person signing this application must be your organization's CEO and have their name on file with the Gambling Control Board <br />If the CEO has changed and the current CEO has not filed a LG200B Organization Officers AFfidavit with the Gambling Control <br />Board, he or she must do so at this time. <br />I have read this application, and all information is true, accurate, and complete and, if applicable, agree to the lease terms as <br />stated in this appl <br />I <br />Signature of Datedesignee may not sign) <br />Mail or fax to: <br />Minnesota Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville, MN 55113 <br />Fax: 651-639-4032 <br />\J <br />No attaehments required. <br />Questions? Contact a Licensing Specialist at 551-539-1900. <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 (and any <br />attachments) will be used by the Gambling Control Board (Board) to <br />determine your organization's qualifications to be involved in lawful <br />gambling activities in Minnesota. Your organization has the right to refuse <br />to supply the information; however, if your organization refuses to supply <br />this information, the Board may not be able to determine your <br />organization's qualifications and, as a consequencer may refuse to issue a <br />permit. If your organization supplies the information requested, the Board <br />will be able to process your organization's application. <br />Your organization's name and address will be public information when <br />received by the Board. All other information provided will be private data <br />about your organization until the Board issues the permit. When the <br />Board issues the permit, all information provided will become public. <br />If the Board does not issue a permit, all information provided remains <br />private, with the exception of your organization's name and address which <br />will remain public. <br />Private data about your organization are available to: Board members, <br />Board staff whose work requires access to the information; Minnesota's <br />Department of Public Safety; Attorney General; commissioners of <br />Administration, Minnesota Management & Budget, and Revenue; <br />Legislative Auditor; national and international gambling regulatory <br />agencies; anyone pursuant to court order; other individuals and agencies <br />specifically authorized by state or federal law to have access to the <br />information; individuals and agencies for which law or legal order <br />authorizes a new use or sharing of information afterthis notice was given; <br />and anyone with your written consent. <br />An equal opportuity employer