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LG230 Application to Conduct Off -Site Gambling <br />Page 2 of 2 <br />5/11 <br />Local Unit of Government Resolution of Approval <br />CITY APPROVAL for a gambling premises <br />located within city limits <br />City name <br />The city council has approved this application <br />by resolution within 90 days of the date of <br />signature below. <br />Signature of city personnel <br />Title Date <br />COUNTY APPROVAL for a gambling premises <br />located in a township <br />County name <br />The county board has approved this application <br />by resolution within 90 days of the date of <br />signature below. <br />Signature of county personnel <br />Title Date <br />Chief Executive Officer (CEO) Acknowledgment <br />10. The person signing this application must be your organization's CEO and have their <br />name on file with the Gambling Control Board. If the CEO has changed and the current <br />CEO has not filed a LG200B Organization Officers Affidavit with the Gambling Control <br />Board, he or she must do so at this time. <br />11. I have read this application, and all information is true, accurate, and complete, and <br />if applicable, agree ta. - -t-he lease terms as stated in this application. <br />CEO signature `_� Date /Z. IS�Zo!l <br />• <br />12. Print name / In �C �Gr2n in5 k' <br />Daytime phone (011-263-24 &`7 <br />Mail or fax to: <br />Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />FAX: 651 - 639 -4032 <br />No attachments required. <br />Reset form <br />Print form: <br />This publication will be made available in alternative format (i.e. large print, Braille) upon request. <br />Data privacy notice: The information requested on <br />this form (and any attachments) will be used by the <br />Gambling Control Board (Board) to determine your <br />organization's qualifications to be involved in lawful <br />gambling activities in Minnesota. Your organization has <br />the right to refuse to supply the information; however, <br />if your organization refuses to supply this information, <br />the Board may not be able to determine your <br />organization's qualifications and, as a consequence, <br />may refuse to issue a permit. If your organization <br />supplies the information requested, the Board will be <br />able to process your organization's application. <br />Your organization's name and address will be public <br />information when received by the Board. All other <br />information provided will be private data about your <br />organization until the Board issues the permit. When <br />the Board issues the permit, all information provided <br />will become public. If the Board does not issue a <br />permit, all information provided remains private, <br />with the exception of your organization's name and <br />address which will remain public. <br />Private data about your organization are available <br />to: Board members, Board staff whose work requires <br />access to the information; Minnesota's Department <br />of Public Safety; Attorney General; Commissioners <br />of Administration, Minnesota Management & Budget, <br />and Revenue; Legislative Auditor, national and <br />international gambling regulatory agencies; anyone <br />pursuant to court order; other individuals and <br />agencies specifically authorized by state or federal <br />law to have access to the information; individuals <br />and agencies for which law or legal order authorizes <br />a new use or sharing of information after this notice <br />was given; and anyone with your written consent. <br />8 <br />