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6/15 LG 2408 Application to Conduct Excluded Bingo Page 2 of 2 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to the Minnesota Gambling Control Board) CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township On behalf of the city, I approve this application for excluded On behalf of the county, I approve this application for excluded bingo activity at the premises located within the city's bingo activity at the premises located within the county's jurisdiction. jurisdiction. Print City Name: Print County Name: Signature of City Personnel: Signature of County Personnel: Title: Date: Title: Date: TOWNSHIP (if required by the county) On behalf of the township, I acknowledge that the organization is applying for excluded bingo activity within the township limits. The city or county must sign before (A township has no statutory authority to approve or deny an submitting application to the application, per Minnesota Statutes, Section 349.213.) Gambling Control Board. Print Township Name: Signature of Township Officer: Title: Date: rina CUTIVE OFFICER'S SIGNATURE (required) n provided in this application is complete and accurate to the best of my knowledge. e Officer's Signature: Date: `f/Q 5 ( gnature st be CEO's signature; designee may not sign) �' rn��VYl MAIL OR FAX APPLICATION &ATTACHMENTS r fax application and a copy of your proof of nonprofit Bingo hard cards and bingo number selection devices may to: be borrowed from another organization authorized to conduct Gambling Control Board bingo. Otherwise, bingo hard cards, bingo paper, and bingo 1711 West County Road B, Suite 300 South number selection devices must be obtained from a distributor Roseville, MN 55113 licensed by the Minnesota Gambling Control Board. To find Fax: 651-639-4032 a licensed distributor,go to www.mn.gov/geb and click on Distributors under the LIST OF LICENSEES, or call An excluded bingo permit will be mailed to your organization. 651-539-1900. Your organization must keep its bingo records for 3-1/2 years. This form will be made available in alternative format Questions? Call a Licensing Specialist at 651-539-1900. (i.e. large print, braille) upon request. Data privacy notice: The information requested will be able to process the application. Your members,Board staff whose work requires on this form (and any attachments)will be used organization's name and address will be public access to the information; Minnesota's Depart- by the Gambling Control Board (Board)to deter- information when received by the Board. All ment of Public Safety;Attorney General;Com- mine your organization's qualifications to be in- other information provided will be private data missioners of Administration, Minnesota Manage- volved in lawful gambling activities in Minnesota. about your organization until the Board issues ment&Budget,and Revenue; Legislative Audi- Your organization has the right to refuse to sup- the permit. When the Board issues the permit, tor,national and international gambling regula- ply the information; however, if your organiza- all information provided will become public. If tory agencies; anyone pursuant to court order, tion refuses to supply this information,the Board the Board does not issue a permit,all infor other individuals and agencies specifically may not be able to determine your organiza- mation provided remains private,with the ex- authorized by state or federal law to have accE tion's qualifications and,as a consequence,may ception of your organization's name and address to the information; individuals and agencies for refuse to issue a permit. If your organization which will remain public. Private data about which law or legal order authorizes a new use or supplies the information requested,the Board your organization are available to Board sharing e was given, nd anyone w with your ion after hwritten is cconsent. 20