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2003-06-25 CC Packet
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2003-06-25 CC Packet
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<br />lG240B Application to Conduct Excluded Bingo <br />Organization Name ~/v//k L;yo~ C!./~ <br /> <br />Page 2 of 2 <br />8/00 <br /> <br />. \ <br /> <br />Chief Executive Officerls Signature <br />The information provided in this applicat~ ~nd accurate to the beSt of my knowledge. Phone number ~ -I'-z<t;. '774-<#-- <br />Chief executive officer's signature .... <br />Name (please print) /A<::",,"a~ oJ. p~'/ Date ~ I~~ <br />local Unit of Government Acknowledgment and Approval <br />If the gambling premises is within city limits, the city must sign this application. <br />On behalf of the city, I hereby approve this <br />application for excluded bingo activity at the Print name of city <br />premises located within the city's jurisdiction. <br /> Signature of city personnel receiving application <br /> Title Date 1 ,- <br />If the gambling premises Is located in a township, both the county and township must sign this application. <br />For the townshio: On behalf of the township, I <br />acknowledge that the organization is applying for <br />excluded bingo activity within the township limits. Print name of township <br />A township has no statutory authority to approve or Signature of township official acknowledging application <br />deny an application (Minn. Stat. sec. 349.213, subd. <br />2). Title Date , 1- <br />For the county: On behalf of the county, I hereby <br />approve this application for excluded bingo activity Print name of county <br />at the premises located within the county's <br />jurisdiction. <br /> (Signature of county personnel receiving application) <br /> Title Oate-l_'_ <br /> <br />This form will be made available in altemative format O.e. large print, Braille) <br />upon request. The information requested on this form (and any <br />attachments) will be used by the Gambling Control Board (Board) to <br />determine your qualifications to be involved in lawful gambling activities in <br />Minnesota. You have the right to refuse to supply the information requested; <br />however, if you refuse to supply this information, the Board may not be <br />able to determine your qualifications and, as a consequence, may refuse <br />to issue you an authorization. If you supply the information requested, the <br />Board will be able to process your application. <br /> <br />Your name and your organization's name and address will be publiC <br />information when received by the Board. All the other information that you <br />provide will be private data about you until the Board issues your <br />authorization. When the Board issues your authorization, all of the <br />information that you have provided to the Board in the process of applying <br />for your authorization will become public. If the Board does not issue you <br /> <br />an authorization, all the information you have provided in the process of <br />applying for an authorization remains private, with the exception of your <br />name and your organization's name and address which will remain public. <br /> <br />Private data about you are available only to the follOlNing: Board members, <br />staff of the Board whose work assignment requires that they have access <br />to the information; the Minnesota Department of Public Safety; the <br />Minnesota Attomey General; the Minnesota Commissioners of <br />Administration, Finance, and Revenue; the Minnesota Legislative Auclitor, <br />national and international gambling regulatory agencies; anyone pursuant <br />to court order, other individuals and agencies that are specifically authorized <br />by state or federal law to have access to the information; individuals and <br />agencies for which law or legal order authorizes a new use or sharing of <br />information after this Notice was given; and anyone with your consent. <br /> <br />Mail Application and Attachment(s) <br /> <br />Send the completed application and a copy of your proof of nonprofit status at least 30 days prior to the <br />activity date to: <br />Gambling Control Board <br />Suite 300 South <br />1711 W. County Rd. B <br />Roseville, MN 55113 <br /> <br />If your application is denied by the local unit of government, do not send the application to the Gambling <br />Control Board. <br />
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