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LG240B Application to Conduct Excluded Bingo 11/17 Page 2 of 2 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to the Minnesota Gambling Control Board) CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township On behalf of the city, I approve this application for excluded On behalf of the county, I approve this application for excluded bingo activity at the premises located within the city's bingo activity at the premises located within the county's jurisdiction. jurisdiction. Print City Name: Mounds View Print County Name: Signature of City Personnel: Signature of County Personnel: Title: _ Date: Title: Date: TOWNSHIP (if required by the county) On behalf of the township, I acknowledge that the organization is applying for excluded bingo activity within the township limits. The city or county must sign before (A township has no statutory authority to approve or deny an submitting application to the application, per Minnesota Statutes, Section 349.213.) Gambling Control Board. Print Township Name: Signature of Township Officer: Title: Date: CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) The information provided in this application is complete and accurate to the best of my knowledge. Chief Executive Officer's Signature: Date:'/7i/i(lii (Signature must be CEO's signature; designee may not sign) Print Name: Katrina E. Joseph MAIL OR FAX APPLICATION & ATTACHMENTS Mail or fax application and a copy of your proof of nonprofit Bingo hard cards and bingo number selection devices may status to: be borrowed from another organization authorized to conduct Minnesota Gambling Control Board bingo. Otherwise, bingo hard cards, bingo paper, and bingo 1711 West County Road B, Suite 300 South number selection devices must be obtained from a distributor Roseville, MN 55113 licensed by the Minnesota Gambling Control Board. To find Fax: 651-639-4032 a licensed distributor, go to www.mn.gov/gcb and click on Distributors under the LIST OF LICENSEES tab, or call An excluded bingo permit will be mailed to your organization. 651-539-1900. Your organization must keep its bingo records for 3-1/2 years. Questions? This form will be made available in alternative format Call a Licensing Specialist at 651-539-1900. (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 deter- mine your organization's qualifications to be in- volved in lawful gambling activities in Minnesota. Your organization has the right to refuse to sup- ply the information; however, if your organiza- tion refuses to supply this information, the Board may not be able to determine your organiza- tion'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 private 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 infor- mation provided remains private, with the ex- ception of your organization's name and address which will remain public. Private data about your organization are available to Board members, Board staff whose work requires access to the information; Minnesota's Depart- ment of Public Safety; Attorney General; Com- missioners of Administration, Minnesota Manage- ment & Budget, and Revenue; Legislative Audi- tor, national and international gambling regula- tory agencies; anyone pursuant to court order; other individuals 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. An equal opportunity employer