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ILG240B Application to Conduct Excluded Bingo <br />6/13 Page 2 of 2 <br />CHIEF EXECUTIVE OFFICER'S SIGNATURE <br />The Information <br />Chief executive <br />Print name <br />provided |nthis application <br />officer's signature <br />is complete and accurate to the besof my knowledge. <br />� ..0"1 -c -4~(.j Date 7 1 - ( � <br />Father 2bumam.11uffLOCAL <br />' <br />UNIT OF GOVERNMENT ACKNOWLEDG ENT <br />On behaif <br />blngo activity <br />jurisdiction. <br />Print clty <br />Signature <br />CITY APPROVAL <br />for a gambling premises <br />located within city limits <br />of the city, 1 approve thls application ror excluded <br />at the premises iocated within the city's <br />name <br />COUNTY APPROVAL <br />for a gambling premises <br />located in a township <br />On behaif of the county, 1 approve this appiicatlon for exciuded <br />blngo acLivlty at the premises iocated wfthln the county's <br />jurisdiction. <br />Print county name <br />u[city personnel <br />Signature ofcounty personnel <br />Title Date <br />Title Date <br />TOWNSHIP - If required by the approving county <br />Onboha|fo[thetnwnah|p,Iachnow|edyethatLheorganizabun <br />is appiying for exciuded blngo activity within the township ilmfts. <br />[Atownship has nostatutory authority ioapprove ordeny <br />anapplication, per Minnesota Statutes 349.16G,SuhdZ.] <br />Print townshlp name <br />Signature of township offlcer <br />Title Date <br />MAIL APPLICATIONAND����EN�` <br />Fax the application and a copy of your proof of <br />nonprofit statutn(as1)ass~032urmall to: <br />Gambling Control Board <br />1711 West CountRoad B, Suite 3OUSouth <br />Roseville, MNss113 <br />You will receive a document from the Gambling Control Board <br />wlth your exciuded permlt number for the bingoactivity. <br />Your organization must keep its bingo records for 3-1/2 years. <br />Questions? <br />Call the Licensing Section of the Gambling Control <br />Board otGs1-538'1gO0. <br />This form will uemade available malternative format (|.e.large print, Braille) <br />upon request. <br />Data privacy privacy notice: The lnformailon requested on Lhls All other information provided will uop+ General; Commissioners f Ad||stu <br />form (and any attachrnenls) wmuevuouuvmaaummmo vote data about your organization until the Minnesota Management u and <br />Control Board (Board) to determine / u 's Board issues ihe permlt, When the F3oard Revenue; lama Auditor, national and <br />qualifications Issues the permit, all Information provided International gambling regulatoryagencies; <br />Minnesota. Your oon| u has the right mrefuse to will become m/ If the Board dt anyone pursuant to court order; oiher Indi- <br />suppiyly the lnformation; however, if your ouou Issue a permit,vmuawand agencies specifically authorized <br />refuses to suppiy this lnrorrnation, theBoard mt be remalne private, with the excepiion of your by tate or fecierai law 10 have access to <br />able to determlne your organlzation's quallrlcatlons and, organizauon's name and address which wIt the information; individuals and agencies <br />as a cansequence, may refuse 10 issue a permii. 9' yourremain pubiic. Prlvata data about your for which law orlegal order authorizes a <br />organization supplies the information requested, the Board organization are available to: Board mem- new usa or sharing of information after this <br />will uvable mprocess the application. Your organization's bers, Board staff whose work requtres notice was given; and anyone wlth your <br />name and address wIll uepublic Information when received access to the information; Minnesota's written consent. <br />by the Board. Departmeni of Public Safety; Attorney <br />