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<br />LG240B Application to Conduct Excluded Bingo <br />Chief Executive Officer's Signature <br /> <br />Page 2 of2 <br />6/08 <br /> <br /> <br />ccurate to the best of my knowledge. <br />Phone number ~01.b0'3, ~t~ <br />Date X11 I 1-B I >>'6 <br /> <br />Name (please print) 0 <br /> <br />Local Unit of Governmen cknowledgment and 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 />Print city name <br /> <br />Signature of city personnel receiving application <br /> <br />Title <br /> <br />Date <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 acknowledge that the organization is applying for <br />excluded bingo activity within the township limits. <br /> <br />Print township name <br /> <br />A township has no statutory authority to approve or Signature of township official acknowledging application <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 application and proof of nonprofit <br />slatus to: <br />Gambling Control Board <br />Suite 300 South <br />1711 W. County Rd. B <br />Rosevllle, MN 55113 <br /> <br />Title <br /> <br />Date_'_'_ <br /> <br />Print county name <br /> <br />Signature of county personnel 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 gambling activity. Your organization must <br />keep its bingo records for 3-112 years. <br /> <br />Questions? Contact the Gambling Control Board at 651-639-4000. <br /> <br />Or, you may fax It to 851-639-4032. <br /> <br />This form will be made available in altemative format (i.e. large print, <br />Braille) upon request. <br /> <br />Data Privacy Notice: The informetlon requested on this form <br />(and any attachments) wtll be used by the Gambling Control Board <br />(Board) to determine your qualifications to be Involved In lawful <br />gambling activities In Minnesota. You have the right to refuse to <br />supply the Information requestad; 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 \'ViII be able to process your applicetion. <br /> <br />Your name and your organization's name and address will be <br />public 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, all information provided <br />remains private, with the exception of your name and your <br />organization's name and address which will remain public. <br /> <br />Private data about you is available to: Board members. Board staff <br />whose work requires access to the information; Minnesota's <br />Department of Public Safety, Attomey General; Commissioners of <br />Administration, Finance, and Revenue; Legislative Auditor, national <br />and intemational gambling regulatory agencies; anyone pursuant to <br />court order; other individuals and agencies that are specifically <br />authorized by state or federellaw to have access to the information; <br />individuals and agencies for which 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 />17 <br />