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LG240B - Application to Conduct Excluded Bingo Page 2 of 2 Organization Name C__Q.�NiA N.6s-\\e, 6 O 1 Q� Chief Executive Officer's Signature The fnf rrnatlon provkied in is tonspie and ate to the beat of my knouMedye. Chief executive officers signabae 1,y113. `.. ' 11. Photwe numbertf ) 1' ! �� Name (please printlCC1/4 , i peke Lt J! Local Unit of Government Acknowie • !m nt and Approval (f ttta gambling premises Is within city limits, the city must sign this application. On behalf of the city, I hereby approve this �\ {' \—\ application for excluded bingo activity at the premises located within the dty's jurisdiction. Print ram f city Signature of city personnel retivittg ap Title, Oat e / 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, I acknowledge that the organization is applying for excluded bingo activity within the township limits. Print name of township A township has no statutory authority to approve or of hip official acknowledging appllcat deny an application (Minn. Stat. sec. 349.213, subd. 2). Title Date I__J ... For the county, On behalf of the county, I hereby approve this application for excluded bingo activity at the premises located within the county's ne�rte of jurisdiction. (Signature of county personnel receiving application) Title Date__/_J_ - This form we be made available in alternative Joined (i.e. large print, Braila) upon request. The information requested on this form (and any attachments) wil be used by the Gambling Control Board (Board) to deierrnine your qualifications to be involved in lawful gambbng activities in Minnesota. You have the right to refuse to supply the infornietionrequesteet however, If you refuse to supply this hfommabon, the Board may not be able to deism** your qualifications and, as a consequence, may refuse to issue you an authodzation. If you supply the information requested, the Board wfl be able to process your application. Your name and your organization's name and address will be public Information when received by the Board. Al the other information that you provide win be private data about you until the Board issues your authorization. When the Board issues your authorization, all of the Information that you have provided to the Board In the process of applying for your authorization will become public. If the Board does not issue you an authorization, all the Information you have provided in the process of applying for an authorization remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are avalable only to the totow Ing: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue: the Minnesota legislative Audhor, 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 suthortzes a new use or sharing of infomatbn after this Notice was given: and anyone with your consent Mail Application and Attachment(s) Send the completed application and a copy of your proof of nonprofit status at least 30 days prior to the activity date to: Gambling Control Board Suite 300 South 1711 W. County Rd. B Roseville, MN 55113 If your application is denied by the local unit of government, do not send the application to the Gambling Control Board.