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Page 2 of 2 LG240B Application to Conduct Excluded Bingo 3/11 Chief Executive Officer's Signature Print form and have CEO sign The information provided in this ap ' ation is romplete nd acc rate to the best of my know/edge. /i a ` � , -� � Chief executive officer's signatu e � Z � � Phone number � � � Name (please prin Date 9 ' Local Unit of Government Acknowledgment and Approval If the gambling premises is within ciry limits, the city must sign this application. On behalf of the city, l approve this application for Print city name excluded bingo activity at the premises located within the city's jurisdiction. Signature of city personnel receiving application Title Date If the gambling premises is located in a township, only the county is required to sign this application. For the county: On behalf of the county, 1 approve print county name this application for excluded bingo activity at the premises located within the county's jurisdiction. Signature of county personnel receiving application Title Date For the township: On behalf of the township, (Township signature is not required) I I 1 acknowledge that the organization is applying for Print township name excluded bingo activity within the township limits. A township has no statutory authority to approve or Signature of township official acknowledging application 'I deny an application (Minn. Stat. 349.166, Subd. 2). � Title Date Mail Application and Attachment(s) Send the application and proof of nonprofit You will receive a document from the Gambling Control Board with status to: your excluded permit number for the gambling activity. Your Gambling Control Board organization must keep its bingo records for 3-1/2 years. Suite 300 South i711 W. Couniy r d. � (�uestions'? Contact the Gambiing Conirol Board at ob1-639-�OCO. Roseville, MN 55113 This form will be made available in alternative format (i.e. large print, Or, you may fax it to 651-639-4032. Braille) upon request. Reset Form Data prlvacy notice: The Informatlon Your organizatlon's name and Private data about your organization are requested on this form (and any address will be public available to: Board members, Board staff attachments) will be used by the information when received by whose work requires access to the Gambling Control Board (BOard) to the Board. All other information information; Minnesota's Department of determine your organization's provided will be private data Pub�ic Safety; Attorney General; qualiflcatlons to be involved In lawful about your organlzation until Commissloners of Adminlstration, gambling activlties in Mlnnesota. Your the Board issues the permit. Minnesota Management & eudget, and organization has the right to refuse to When the Board issues the Revenue; Legislative Auditor, national and supply the information; however, If your permit, all information provided international gambling regulatory agencles; organlzatfon refuses to supply thls will become public. If the Board anyone pursuant to court order; other informatlon, the Board may not be able does not issue a permlt, all individuals and agencies specifically to determine your organization's information provlded remains authorized by state or federal law to have qualifications and, as a consequence, private, with the exception of access to the Information; individuals and may refuse to issue a permit. If your your organization's name and agencies for which law or Iegal order organlzation supplies the information address which will remain public. authorizes a new use or sharing of requested, the Board will be able to information after this notice was given; and process your organization's application, anyone with your written consent. ��