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Page 2 of 2 Application to Conduct Excluded Bingo - LG240B 3/99 1 / I Organization Name tna «-tr , fLo Lin 5 eJtti -t Chief Executive Officer's Signature The information provided in this application is complete and to to the best of my knowledge. Chief Executive Officer's signature Name (please print) <JIM &lit Date d / old / OO Local Unit of Government Acknowledgment and Approval If the gambling premises is within city limits, the city must sign this application. • On behaff of the city, I hereby approve this application for excluded bingo activity at the premises located eflkev' ge. Print na of c within the citysjurisdictan. Signature of city personnel receiving application Title y At Date if /22- /OD If the gambling premises is located in a township, both the county and township must sign this application. For the township: On behalf of the township, I acknowledge that the organization is applying for excluded bingo activity within the township limits. Print name of township • A township has no statutory authority to approve or Signature of township official acknowledging application deny an application (Minn. Stat. sec. 349.213, subd. 2). Title Date / / For the county: On behalf of the county, I hereby approve this application for excluded bingo activity at the premises located within the countys jurisdiction. Print name of county (Signature of county personnel receiving application) Title Date / / Mail Application and Attachment(s) Acknowledgment of Gambling Control Board Send the completed application and a copy of your Your request to conduct excluded bingo has been received proof of nonprofit status at least 30 days prior to the and is acknowledged by the Gambling Control Board. activity date to: Acknowledged by: Gambling Control Board 1711 W. County Rd. B, Suite 300 South Date / / _ Roseville, MN 55113 Licensing Specialist If your application is denied by the local unit of authorization. When the Board issues your authorization, all of the goverment, do not send the application totheGambling information that you have provided to the Board in the process of Control Board. applying for your author®tion will become public. If the Board does not issue you an authorization, a the information you have provided This form will be made evadable in altemative format (i.e. large print, in the process of applying for an authorization remains private, with Braille) upon request. The information requested on this form (and the exception of your name and your organization's nave and address any attachments) wit be used by the Gambling Control Board (Board) which will remain pubic. to determine your qualifications to be involved in lawful gambling private data about you are available only to the following: Board activities in Minnesota. You have the right to refuse to supply the members, staff of the Board whose work assignment requires that information requested; however, if you refuse to supply this they have access to the information; the Minnesota Department of information, the Board may not be able to det mikie your qualifications Public Safety: the Minnesota Attorney General; the Minnesota and, as a consequence, may refuse to issue you an authorization. If Commissioners of Administration, Finance, and Revenue; the you supply the information requested, the Boani will be able to process Minnesota Legislative Auditor, national and intemational gambling your application. regulatory agencies; anyone pursuant to court order, other individuals Your name and your organization's name and address wtl be public and agencies that are specifically authored by state or federal law information when received by the Board. AI the other information that to have access to the information; individuals and agencies for which you provide will be private data about you until the Board issues your law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.