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LG240B Application to Conduct Excluded Bingo 6/12 Page 2 of 2 CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application is complete and accurate to the best of my knowledge. Chief executive officer's signature Print name t \e Oa -vfC� K,b Date I/ LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT CITY APPROVAL for a gambling premises located within city limits On behalf of the city, I approve this application for excluded bingo activity at the premises located within the city's jurisdiction. Print city name Signature of city personnel Title Date COUNTY APPROVAL for a gambling premises located in a township 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 Title Date TOWNSHIP - If required by the approving county. On behalf of the township, I acknowledge that the organization is applying for excluded bingo activity within the township limits. [A township has no statutory authority to approve or deny an application, per Minnesota Statutes 349.166, Subd 2.] Print township name Signature of township officer Title Date MAIL APPLICATION AND ATTACHMENT Send the application and a copy of your proof of nonprofit status to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Reset Form You will receive a document from the Gambling Control Board with your excluded permit number for the bingo activity. Your organization must keep its bingo records for 3 -1/2 years. Questions? Call the Licensing Section of 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 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 the application. Your organization's name and address will be public information when received by the Board. All other information provided will be pri- vate 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 mem- bers, 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 pursuant to court order; other indi- viduals 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.