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<br />LG240B Application to Conduct Excluded Bingo <br />.~;....,,~...... <br /> <br />Page 2 of2 <br />6/07 <br /> <br /> <br /> <br />The information provided in this eppHcation is complete and accurate to the best of my knowledge. <br />Phone number (05j-'1ll/fltft/ <br /> <br />Date I ,:lZ2....JOl <br /> <br />Name (pleaee print . /L{...... <br /> <br />l.C)CatUQIt.OfGov,tJit'l'u.nfACi(no"J!1entand Approval <br /> <br />If the gambling premises Is within city limits. the city must sign this application. <br /> <br />On behalf of the city, I approve this application for <br />excluded bingo activity at the premises located within <br />the city's jurisdiction. <br /> <br /> <br />Print city name <br /> <br />Signature of city personnel receiving application <br /> <br />~e On , <br /> <br />If the gambling premises Is located In a township, both the county and township must sign this application. <br /> <br />For the township: On behalf of the township, <br />I ecknowIedge that the organization is apply/ng for <br />excluded bingo activity within the township limits. <br /> <br />, <br /> <br />Print township name <br /> <br />A township has no statutory authority to approve or Signature of township official acknowledging apptication <br />deny an application (Minn. Stat 349.213, Subd. 2). <br /> <br />For the county: On behalf of the county, I approve <br />this application for excluded bingo activity at the <br />premises located within the county's jurisdiction. <br /> <br />Mall Application and Attachment(s) <br /> <br />Send the apptication and proof of nonprofit <br />s1atus m: <br />GambHng control Board <br />Suite 300 SOUth <br />1711 W. COUnty Rd. B <br />Rosevllle, MN 11113 <br /> <br />Or, you may fax It to 811..3t~32. <br /> <br />Date_,_'_ <br /> <br />Trtle <br /> <br />Print county name <br /> <br />Signature of county personnal receiving application <br /> <br />Title <br /> <br />Date_'_'_ <br /> <br />You will receive a document from the Gambling Control Board with <br />your permit number for the gambDng activity. Your organization must <br />keep its blngo records for 3-112 years. <br /> <br />Questtons? Contact the GambDng Control Board at 651-639-4000. <br /> <br />This form will be made available in alternative format (i.e. large print, <br />Braille) upon request <br /> <br />Data Privacy NotIae: The information requested on this form <br />(and any atIIIchments) wID be used by the Gambling Control Board <br />(Board) to determine your quaJlftcatlons to be Involved In lawful <br />gambling activities In Minnesota. You have the right to refuse to <br />supply the information requested; however, If you refuse to supply <br />this information, the Board may not be able to determine your <br />qualifications and, as a consequence, may refuse to Issue you <br />an authorization. If you supply the information requested, the <br />Board wID be able to process your application. <br /> <br />Your nsme and your organization's nsme and address will be <br />pubRc information when received by the Board. All the other <br />Information will be private data until the Board Issues your <br />authorization and the information then becomes public. If the <br /> <br />Board does not Issue you an authorization, an information provided <br />remains private, with the exception of your name and your <br />organization's name and address whlc:h will remain public. <br /> <br />PrIvate dete about you Is available to: Board members, Board staff <br />whose work requires access to the Information; Minnesota's <br />Department of PubDc Safety, Attomey General; Commissioners of <br />Administration, FInam:8, and Revenue; Legislative Auditor, national <br />and international gambling regulstory agencies; anyone pursuant to <br />court order; other individuals and agencies that are specifically <br />authorized by state or federal law to have access to the Infonnatlon; <br />IndMduals and agencies for whlc:h law or legal order authorizes a <br />new use or sharing of information after this Notice was given; and <br />anyone with your consent. <br /> <br />33 <br />