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LG,2408 to CoilradliLliCt 1111..:..xduided i R-11111111"ago Page 2 of 2
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<br /> LOCAL UNIT" OF' GOVERNMEyv r ACKNOWLEDGMEIN 1111' (requir-ad apI11*111catlioll
<br /> til-lie Minnesota Gairrabling Control Board)
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<br /> CITY ARPROVAll COUNTY A11154115rROVAilll...
<br /> fla gaglimbling p i! i
<br /> iii.,ilividses fair a gailrinbliling pr mm
<br /> PocAtedwit1hiiin city filil,irill Iloiante cli ll altow r ql:il,
<br /> On belhallf of the city, I all til-fls aplipfication for exdudied On Ibehallf of l CIDUIrIty, 11. app:IrDve thils apipillicardoin for excluded
<br /> l act.11vity at the preirrilises located wilthiri thie city"s., blirigo aii:tivlity at th Ipreirnlises located wiltl the coil.iinl
<br /> "'I"'Sdilctioil'i
<br /> '113irlint City Name: Phint il l ...........................................................................................
<br /> "54griartuire of Clity Personnel: Sligiriatuii e of Coilinty F"eirsoininielk:
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<br /> Tltlle�!.................................................. Date!::.............. I Titley
<br /> F`OWNS11111111111 (l[f 111"eqUilli,vid by thip.,cou:nty)
<br /> Oin bell of ti-iietowil'ishillpi, Il adkinowIledge that the orgail'ilization
<br /> is appllying for excludied t:i1inglo actiVity w1ithilin the townshillp firrilits.
<br /> 1111 he City olir coiil.rinityrnusilll:�iii 111:mfdre (A towinshilp has rio s,tatutoi�,y,niutl-1,liair--ity toalp1pi"cive ol,' deny an
<br /> subimilittirtg appillica"lel ain 'Ido 'Uhle alpqpillcatlon, 1peii Wrlinesota Statifte,,ii, Sectlion,349.213.)
<br /> Golinibling Coil-litill 11131oard, l int Townsh'illp Narrile: ...................................................................
<br /> Slignature of Fong inslitip Oil
<br /> ... ....................................................................... Date��
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<br /> CF11,EF:! 11EXIEECU I IVE OFFICIIII..1.11VS SIGINATURECilreqiil.dred)
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<br /> The linformialtlion 1plrDVided iiia this alpiplilication !is coinniplete aind acourate,tD the Ibuast Of 171)r 4i,,riowlledige,
<br /> ChliefIl xecutivie Officer's Slliginatiuire:: ................................................................................... ...................................................Dater: ..............................................................................................
<br /> (Sigrature irniust The CE.:Cirs siligirrature, diesfigirnee rinay not sigirl)
<br /> lPir lint Ill
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<br /> MAIL OR F"AX APPLICATION &ATTACHMENTS
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<br /> Mafll nir&:lx.alp pilication aind a copy of youir piroof of 111101i'llpirofit Bilingo haird caildrs aind l riluirril.mi sellectiori devilces rinay
<br /> Sl to�: b,E..,. binirrowed Itinim airmtheir loir�gF.nlizatilo�,i,a.,it�h-iioir,,ilzef.i,to coriduict
<br /> Minnesota GairtIbIling l l Otherwise, t:i1inqii) haird c,
<br /> airds, l palper, arid l
<br /> 1711 West Coluinty l B, 'Suite 3010SIDLi'U'll nuirrOber selllectlioii'l devilms must The obtallned,fmin a, dilstil
<br /> RclsevflHle, Il N 5511.3 Hicerised Iby the.., 111411inil,wescita Giainnilb:111ing Cuntt'dl l "117o Rind
<br /> F:,aw:: 651-639 4-032 a 11[censed idlistrilbutoir, go to larW1w.nsrii..9Pv/gcb and idlidic
<br /> on Distributors uindeii- the,1197"OFLY CE"WFUFES talb,air c:a1l1l
<br /> Ain exidliuclied b:lingo plenrinnit Will be irrialillivad 10 YOUli"Dirgair'lliz.ation. 16,51-5319 1901l
<br /> Youir o:irgainiza lon irriust keep Its 11�fingo recoircisfibr 3 1/2'yis',
<br /> Quieqtloan ri? "Ttilis forly-i wilIll Ibe made r:lvalillalblle!in allteirriative Forimat
<br /> Cafll a 11 liceirising Specialilist at 651.,539 :119100, (i.ie. large prilint, birafflie) UPOrll
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<br /> Data privacy notice: The information requested will be able to process the application. Your members,Board staff whose work requires
<br /> on this form(and any attachments)will be used organization's name and address will be public access to the information; Minnesota's Depart-
<br /> by the Gambling Control Board(Board)to deter- information when received by the Board. Ali ment of Public Safety;Attorney General;Com-
<br /> mine your organization's qualifications to be in- other Information provided wfll be private data milssioners of Administration,Minnesota Manage-
<br /> volved in lawful gambling activities in Minnesota, about your organization until the Board issues ment&Budget,and Revenue; Legisiative Audii-
<br /> Your organization has the right to refuse to sup- the permit. When the Board issues the permit, tor,nationall and International gambling regula-
<br /> ply the Information; however,if your orgariliza- all information provided will become public, if tory agencies;anyone pursuant to court order;
<br /> tion refuses to supply this Information,the Board the and does not issue a permit,ail infor- other individuals and agencies specirically
<br /> may not be able to determine your Grganiza- mation provided remains private,with the ex- authorized by state or federal law to have access
<br /> tfon's qualifications and,as a consequence,may ception of your organization's name and address to the information, individuals and agencies for
<br /> refuse to issue a pe it. If your organization which will remain public. Private data about which law or legal order authorizes a new use or
<br /> supplies the information requested,the Board your organization are available to Board sharing of information after this notice was
<br /> given;and anyone with your written consent.
<br /> An equal appartunity employer
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