2003-06-25 CC Packet - Laserfiche WebLink

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lG240B Application to Conduct Excluded Bingo Organization Name ~/v//k L;yo~ C!./~ Page 2 of 2 8/00 . \ Chief Executive Officerls Signature The information provided in this applicat~ ~nd accurate to the beSt of my knowledge. Phone number ~ -I'-z<t;. '774-<#-- Chief executive officer's signature .... Name (please print) /A<::",,"a~ oJ. p~'/ Date ~ I~~ local Unit of Government Acknowledgment and Approval If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I hereby approve this application for excluded bingo activity at the Print name of city premises located within the city's jurisdiction. Signature of city personnel receiving application Title Date 1 ,- If the gambling premises Is located in a township, both the county and township must sign this application. For the townshio: On behalf of the township, I acknowledge that the organization is applying for excluded bingo activity within the township limits. Print name of township A township has no statutory authority to approve or Signature of township official acknowledging application deny an application (Minn. Stat. sec. 349.213, subd. 2). Title Date , 1- For the county: On behalf of the county, I hereby approve this application for excluded bingo activity Print name of county at the premises located within the county's jurisdiction. (Signature of county personnel receiving application) Title Oate-l_'_ This form will be made available in altemative format O.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. 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 an authorization. If you supply the information requested, the Board will be able to process your application. Your name and your organization's 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 authorization. When the Board issues your authorization, all of the information that you have provided to the Board in the process of applying for your authorization will become public. If the Board does not issue you an authorization, all the information you have provided in the process of applying for an authorization remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are available only to the follOlNing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attomey General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auclitor, 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 information; 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. Mail Application and Attachment(s) Send the completed application and a copy of your proof of nonprofit status at least 30 days prior to the activity date to: Gambling Control Board Suite 300 South 1711 W. County Rd. B Roseville, MN 55113 If your application is denied by the local unit of government, do not send the application to the Gambling Control Board.