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