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LG240B Application to Conduct. Excluded Bingo 6115 Page 2of2 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 township On behalf of the city, I approve tis application for excluded n behalf of the county, I a pprove this application r excluded bingo activity at tate premises located within the city's bingo activity at the premises located within the county's jurisdiction. )uric i on. Print City kaurnrmi print County Name: Signature of City Personnel: Signature of County Personnel: Title: Dates ......,,,..Title: Date: TOWNSMZP (if I ) ................ On behalf of the township,acknowledge that the organization ��l The city o r county must sign befo're is applying for excluded bingo activity within the township limits. (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 TownshipName: Signature of Township r: Titley Date: CHIEF EXECU77VE OFFICER"S SIGNATURE (required) The information provided int its application is complete and accurate a best of my knowledge. Chief ExecutiveOfficer's Signature, (sign u must be C s signature; d lgnee ay not sign) Print arae: MAIL OR FAX APPLICATION & ATTACHMENTS Mail or fax application and a copy of your proof of nonprofit status : Bingo hard cards and bingo number selection devices may Minnesota amblin Control Board be borrowed from another organization authorized to conduct bingo. Otherwise, bingo hard cards, bingo paper, and bingo 1711 West County Road, Suite 300 South Roseville, MN 5 113 number selection devices must be obtained from a distributor Fax: 651-639-4032 licensed by the Minnesota Gambling Control Board. To find a licensed distributor, go to www -Mn g0v19cib and click An excluded bingo permit will be mailed to your organizatJon. on Oistributars under the LEST OF LICENSEES, or call Your organization must keep ft bingo records for 3-1/2 years. 651-539-1900. N a Licensing Speciale at 651-539-1900. This form will be made available in alternative format (i.e. large print, braille) upon request. vara privacy notice: The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to deter- mine your organization's qualifications to be in- volved in lawful gambling activities in Minnesota. Your organization has the right to refuse to sup- ply the information; however, if your organiza- tion refuses to suppiy this information, the Board may not be aide to determine your organiza- tion's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the information requested, the Board will be able to process the application. Your organizations name and address will be public information when received by the Hoard. All other information provided will be private data about your organization until the Board issues the permit. when the Board Issues the permit, all information provided will become public. If the Board does not Issue a permit, all infor- mation provided remains private, with the ex- ception of your organization's name and address which will remain public. Private data about your organization are available to Board An equal opportunity employer 38 members, Board staff whose work requires access to the information; Minnesota's Depart- ment of Public Safety; Attorney General; Com- missioners of Administration, Minnesota Manage- ment & Budget, and Revenue; Legislative Audi- tor, national and International gambling regula- tory agencies; anyone pursuant to court order; other individuals and agencies spec9fcally 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 written consent.