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LG240B Application to Conduct Excluded Bingo 6/13 Page 2 of 2 CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application is complete and accurate Chief officer's signature Kik to the best of my knowledge. ypt� ^ ,�,// Date CJ -a 8" I executive Print name _....__he s 3-• ?).2..1/444 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 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 city personnel Signature of county personnel Title Date 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. [Lot Nltit+O�il'1r�t$;Y�1� [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 Fax the application and a copy of your proof of nonprofit status to (651) 639-4032 or mail to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 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? Cali the Licensing Section of the Gambling Control Board at 651-539-1900. This form will be made available in alternative format (i.e. large print, Braille) upon request. Data privacy notice: The information requested on this All other information provided will be pri- General; Commissioners of Administration, form (and any attachments) will be used by the Gambling vote data abot 1 your organization until the Minnesota Management & Budget, and Control hoard (Board) to determine your organization's Board issues t to permit. When the Board Revenue; Legislative Auditor, national and qualifications to be involved in lawful gambling activities in issues the permit, all information provided international gambling regulatory agencies; Minnesota. Your organization has the right to refuse to will become public. If the Board does not anyone pursuant to court order; other indi- suppiy the information; however, if your organization issue a permit, all information provided viduals and agencies specifically authorized refuses to supply this information, the Board may not be remains private, with the exception of your by state or federal law to have access to able to determine your organization's qualifications rind, organization's name and address which will the information; individuals and agencies as a consequence, niay refuse to issue a permit. If your reinain public. Private data about your for which law or legal order authorizes a organization supplies the information requested, the Board organization are available to: Board menr new use or sharing of information after this will be able to process the application. Your organization's bens, Board staff whose work requires notice was given; and anyone with your name and address will be public information when received access to the information; Minnesota's written consent. by the Board. Department of Public Safety; Attorney