2010-07-14 CC Meeting Packet - Laserfiche WebLink

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LG240B Application to Conduct Excluded Bingo Chief Executive Officer's Signature Signature of city personnel receiving application ie The information provided in this application is complete and accurate to the best of my knowledge. Chief executive officer's signature `"�� `�� Phone number 7M - 7 a - 5 1 Name (please print) Date �C' /��/ Z0 Local Unit of Government Acknowledg ent and-Approval If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I approve this application for excluded bingo activity at the premises located within Print city name the city's jurisdiction. If the gambling premises is located in a township, only the county is required to sign this application. For the county: On behalf of the county, 1 approve Print county name this application for excluded bingo activity at the premises located within the county's jurisdiction. Signature of county personnel receiving application Title Date / / For the township: On behalf of the township, (Township signature is not required) I acknowledge that the organization is applying for excluded bingo activity within the township limits. Print township name A township has no statutory authority to approve or Signature of township official acknowledging application deny an application (Minn. Stat. 349.166, Subd. 2). Title Mail Application and Attachment(s) Send the application and proof of nonprofit status to: Gambling Control Board Suite 300 South 1711 W. County Rd. B Roseville, MN 55113 Or, you may fax it to 651 - 639 -4032. Data privacy notice: The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your organization's qualifications to be involved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the information: however, if your organization refuses to supply this information, the Board may not be able to determine your organization'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 your organization's application. Page 2 of 2 1/10 Date / You will receive a document from the Gambling Control Board with your excluded permit number for the gambling activity. Your organization must keep its bingo records for 3 -1/2 years. Questions? Contact the Gambling Control Board at 651 - 639 -4000. This form will be made available in alternative format (i.e. large print, Braille) upon request. Your organization's name and address will be public information when received by the Board. 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 information provided remains private, with the exception of your organization's name and address which will remain public. Private data about your organization are available to: Board members, Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuantto court order, other individuals and agencies specifically 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. 15