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CCP 02-14-2000
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CCP 02-14-2000
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<br />Application to Conduct One-Day Off-Site Gambling - LG230 <br /> <br />Who May Apply? <br /> <br />Only organizations that have an active <br />organization license and premises permit may <br />apply to conduct one-day off-site activity. An <br />organization may only conduct one one-day off- <br />site activity per calendar year for a period of up to <br />12 hours on that day. <br /> <br />Licensed Organization Information <br /> <br />Print the following information: <br />1. organization name; <br />2. class (A, B, C, or D, listed on your current <br />organization license); <br />3. base license number (five digits following the <br />class type); <br />4. expii'stion date of your current license (listed <br />on your current organization license); and <br />5. name and daytime phone number of your <br />chief executive officer (CEO), the person <br />responsible for your organization (such as the <br />president or commander). <br /> <br />The person signing this application must be on <br />file with the Gambling Control Board as the CEO <br />of your organization. If the CEO has changed <br />during the term of your license and has not filed <br />an Organization Officers Affidavit - LG200B with <br />the Gambling Control Board, he or she must do <br />so at this time. If you are unsure.if your current <br />CEO has filed an LG200B, contact your licensing <br />specialist. <br /> <br />RE <br />FEB - 2 ZeO\} <br /> <br />,1"""'.\ '"ll n, ~;i\t)i..li <br />..,J<, .,. <br /> <br />This publication will be made available in <br />aKemativeformat (i.e. large print, Braille) <br />upon request. The information requested <br />on this form (and any attachments) will <br />be used by the Gambling Control Board <br />(Board) to determine your qualifications <br />to be involved in lawful gambling activities <br />in Minnesota, and to assist the Board in <br />conducting a background investigation <br />of you. You have the right to refuse to <br />supply the information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able to <br />determine your qualifications and, as a <br />consequence, may refuse to issue you a <br />permK. If you supply the information <br />requestad, the Board will be able to <br />process your application. <br /> <br />This form may require the disclosure of <br />your Social Security number. If so, your <br /> <br />Page20f2 <br />10199 <br /> <br />Type of Gambling Activity <br />Check the box(es) indicating the type(s) of <br />gambling that will be conducted. You may only <br />conduct gambling activities authorized by the <br />class of your organization license. <br />For example: If you have a Class B <br />organization license, you may conduct <br />pull-tabs, paddlewheels, tipboards, and <br />raffles-but not bingo. Bingo is not <br />allowed under a Class B organization <br />license. <br /> <br />e <br /> <br />If you want to conduct bingo activity and do not <br />have a Class A organization license, you must <br />submit a letter signed by your CEO requesting <br />that your organization's license class be <br />changed to Class A. <br /> <br />Questions? Direct questions to your licensing <br />specialist at 651-639-4000. Hearing impaired <br />individuals using a TTY may call the Minnesota <br />Relay Service at 1-800-627-3529 and ask to <br />place a call to 651-639-4000. <br /> <br />What and Where to Mail <br />At least 30 days prior to the date of your <br />scheduled activity, submit the following: <br />1) this application, <br />2) the resolution of approval from the local <br />unit of government, and <br />3) a copy of the lease agreement, if required. <br /> <br />. <br /> <br />Mail to: Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Rosevllle, MN 55113 <br /> <br />Social Security number will be used to <br />determine your compliance wKh the tax <br />laws of Minnesota. Authorization for <br />requiring your Social Security number is <br />found at 42 U.S.C. 405 (c)(i). <br /> <br />Your name and address will be public <br />information when received by the Board. <br />All the other information that you provide <br />will be private data about you until the <br />Board issues your permit. When the <br />Board issues your permit, all of the <br />information that you have provided to the <br />Board in the process of applying for your <br />permi! will become public except for your <br />Social Security number, which remains <br />private. If the Board does not issue you <br />a permit, all the information you have <br />provided In the process of applying for a <br />permK remains private, with the exception <br />of your name and address which will <br /> <br />remain public. <br /> <br />Private data about you are available only <br />to the following: Board members, staff of <br />the Board whose work assignment <br />. requires that they have access to the <br />infonnation; the Minnesota Department <br />of Public Safety; the Minnesota Attorney <br />General; the Minnesota Com-missioners <br />of Administration, Finance, and Revenue; <br />the Minnesota Legislative Auditor, <br />national and International gambling <br />regulatory agencies; anyone pursuant to <br />court order; other Individuals and <br />agencies that are specifically authorized <br />by state or federal law to have access to <br />the infonnation: individuals and agencies <br />for which law or legal order authorizes a <br />new use or sharing of Information after <br />this Notice was given; and anyone with <br />your consent. <br /> <br />e <br />
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