07-11-2007 Council Agenda - Laserfiche WebLink

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_G240B Application to Conduct Excluded Bingo Page 2 of 2 Chief Executive Officer's Signature The information provided in thi. • ' Lion is complete at ci a -c irate to the best of my knowledge. 1111111,11. Chief executive officers signet l/ .ee &i �i ,ate, Phone number l„S/ 5'(f7% _ or Name (please print) g me • A f• • SO/0 Date 67 / 03 / 07 Local Unit of Government Acknowledgment 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 excluded bingo activity at the premises located the city's jurisdiction. for 6177 r /,+AA)4i n n Print city name 0� on-a- C //r[ within Signature of city personnel receiving application Title A`1/Ah /57AS 2/t Date 07/03 /07 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, acknowledge that the organization is applying excluded bingo activity within the township limits. A township has no statutory authority to approve deny an application (Minn. Stat. 349.213, Subd. 2). for fit1 I IV Print township name /T' AI or Signature of township official acknowledging application Title Date / / For the county: On behalf of the county, I approve this application for excluded bingo activity at the premises located within the county's jurisdiction. Print county name Signature of county personnel receiving application Title Date / / 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. You will receive a document from the Gambling Control Board with your 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. Data Privacy Notice: The information requested on this form (and any attachments) will be used by the Gambling Cont of Board (Board) to determine your qualifications to be involved 'n lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you an authorization. If you supply the information requested, the Board will be able to process your application. Your name and your organization's name and address will be public information when received by the Board. All the other information will be private data until the Board issues your authorization and the information then becomes public. If the Board does not issue you an authorization, all information provided remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you is available to: Board members, Board staff whose work requires access to the information; Minnesota's Department of Public Safety, Attorney General; Commissioners of Administration, Finance, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order: other individuals and agencies that are 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 consent. 5