Fillable GamblingEventPermit2019Fillable City of Farmington

Fill Online, Printable, Fillable, Blank GamblingEventPermit2019Fillable City of Farmington Form

Use Fill to complete blank online CITY OF FARMINGTON (MN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

GamblingEventPermit2019Fillable City of Farmington

On average this form takes 18 minutes to complete

The GamblingEventPermit2019Fillable City of Farmington form is 6 pages long and contains:

  • 3 signatures
  • 0 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Farmington

BROWSE CITY OF FARMINGTON (MN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CITY OF FARMINGTON
LICENSE PROCESS
Gambling Event Permit
A gambling event permit is required to regulate gambling activities such as raffles and bingo. Please review
Title 3 Chapter 19 of the city code for complete details. All permits are effective for the dates listed on the
permit. If you are having more than one event per year you can list all the event dates on one permit. Dates
must be on the permit at the time of submittal. Following is the process to obtain a gambling event permit:
1. Application forms and fees should be submitted to the city of Farmington at least two weeks prior to
a City Council meeting.
2. A background check will be performed by the Farmington Police Department.
3. Approval is required by the City Council. Council meetings are held the first and third Mondays of
every month.
4. Upon City Council approval, a permit is issued. The entire application process takes approximately
two weeks. Upon City Council approval, the applicant should submit the proper forms and fee to the
state if required.
5. Investigation Fee: $50/year
If you have questions, please contact:
Cynthia Muller, Administrative Assistant
City of Farmington
430 Third Street
Farmington, MN 55024
Tel: 651-280-6803
E-mail: CMuller@FarmingtonMN.gov
Checklist for Gambling Event Permit
Business Name: __________________________ Event Date _________
Please return this list with your application materials. Incomplete applications cannot be
processed until all of the items listed are received and complete.
Required Applicant City Staff
Documents Initials Initials
1. Gambling Event Permit Application (Form GE2009) ____________ ____________
2. All applicable Fees (See fee schedule below) ____________ ____________
3. All applicable information supporting the basis for exclusion __________ __________
or exemption from license requirement.
4. State application (for signature). __________ __________
Police background check approved by _______________________________ Date _______________
License Fees
Investigation Fee $50
Application for Gambling Event Permit
(Form GE2009)
APPLICANT INFORMATION
Applicant Name: ________________________________________Title: ___________________________
(First) (Middle) (Last)
Applicant Address: _____________________________________________________________________
(Street) (City, State, ZIP)
Applicant Home Phone: _______________________________ Date of Birth: _______________________
BUSINESS INFORMATION
Business Name/Organization:_____________________________________________________________
Address:______________________________________________________________________________
(Street) (City, State, ZIP)
Business Phone: __________________ FAX:___________________ Email: _______________________
PROPOSED GAMBLING EVENT LOCATION INFORMATION
Address: _____________________________________________________________________________
Telephone Number: ________________________ FAX: _________________________
Property Owner: _______________________________________________________________________
Property Owner Address: ________________________________________________________________
(Street) (City, State, ZIP)
Property Owner Telephone Number: _______________________________________________________
Description of gambling activities to be conducted on premises by organization; including days & hours:
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________
PROVIDE ALL RELEVANT INFORMATION SUPPORITNG THE BASIS FOR EXCLUSION OR
EXEMPTION FROM LICENSE REQUIREMENT UNDER ONE OF THE FOLLOWING APPLICABLE
SECTIONS:
Minnesota Statute § 349.166, subd. 1 (a):
Name of fair or civic celebration: ______________________________________________________
Number of consecutive days of bingo operation: __________________________________________
Number of bingo occasions conducted by organization during the current calendar year: __________
Minnesota Statute § 349.166, subd. 1 (b):
Value of prizes for a single bingo game: $__________
Value of total prizes awarded at a single bingo occasion: $__________
Number of bingo occasions held by the organization or at the facility each week: __________
Participants allowed to play in a bingo game: __________
Name and address of manager appointed to supervise the bingo and registered with the Gambling Control
Board:_______________________________________________________________________________
Minnesota Statute § 349.166, subd. 1 (c):
Value of all raffle prizes awarded by the organization during calendar year: $__________
Minnesota Statute § 349.166, subd. 2 (a):
Number of lawful gambling events during the year: __________
Value of prizes for lawful gambling in a calendar year: $__________
Exemption identification number: ___________________
I hereby certify that all statements made in this application are true and complete to the
best of my knowledge. I understand that any misstatements or omissions of material facts
may result in the disqualification or denial of the license. I authorize the City of Farmington
to investigate the information and contact persons/organizations named on this
application. The undersigned agrees that the gambling event will conform to all applicable
state laws, Gambling Control Board regulations, and ordinances of the City of Farmington.
Name of Applicant (please print) ___________________________________________________
Signature _________________________________________________Date _______________
APPROVALS
Department Signature Date Comments
Police ______________________ __________ _____________________________
City Clerk/Deputy Clerk_____________________ __________ _____________________________
Applicant will need copy of permit and signed resolution to send to the State of Minnesota.
click to sign
signature
click to edit
click to sign
signature
click to edit
CITY OF FARMINGTON
GENERAL AUTHORIZATION AND RELEASE OF DATA
In order to comply with State and Federal Data Privacy Act Laws, the City of Farmington is requesting your
authorization and consent to permit the City to conduct a background investigation. Please provide the
following personal data, read the paragraphs below and sign where indicated.
Full Name: ____________________________________________________________________
(First, Middle, Last)
Address: ______________________________________________________________________
Number Street City County State Zip Code
Date of Birth: _________________ Driver’s License Number: __________________________
Month/Date/Year
Have you ever been convicted of any crime, either felony or misdemeanor? ________ If yes, please state
place and nature of offense: _____________________________________________
______________________________________________________________________________
I, the undersigned, hereby authorize and grant my informed consent to permit the Bureau of Criminal
Apprehension (hereafter “BCA”) and the Farmington Police Department (hereafter “FPD”) to release to and
make available to the City of Farmington, Minnesota (hereafter “City”) and/or its representatives all data
classified as private which concerns me and which may be in your possession. The data, classified as
private under M.S. 13.02, Subd. 12, includes all data which has been collected, created, received, retained or
disseminated in whatever form which in any way relates to my dealings with the BCA and/or the FPD. I
understand the purpose of permitting the City to have access to this information is to determine my
suitability for licensure.
By signing this authorization, I hereby release the BCA and the FPD from any and all liability which
otherwise may or does accrue as a result of the release of any and all data, regardless of its accuracy. I also
release the City from any and all liability for its receipt and use of data received pursuant to this consent. I
understand that if I am rejected on the basis of a criminal conviction, I will be notified in writing and be
given rights of redress subject to applicable laws. I also understand that I am not legally required to sign
this form, but if I do not, the City will not be able to determine whether my conviction record is a license-
related consideration.
This authorization shall be valid for a period of one year, but I reserve the right, at any time prior to that
expiration, to cancel the written authorization by providing written notice to the City of that intent.
_______________________________________________ ________________________
(Signature) (Date)
_______________________________________________
(Full Name Printed)
Please return to:
City of Farmington
Attn: Administration
430 Third Street
Farmington, MN 55024
click to sign
signature
click to edit
CITY OF FARMINGTON – DATA PRACTICES ACT NOTICE
Minnesota law requires that you be informed of your rights as they pertain to private information (“private
data”) collected from you by the City of Farmington (“the City”). Private data is that information held by
the City which is available to you, but not to the public.
You have the right to refuse to provide the information requested on this application form, however, without
certain information, the City may be unable to approve the license applied for. If you feel that certain
information requested is an unwarranted invasion of privacy, please contact the Human Resources Director.
The dissemination and the use of private data we collect is limited to that necessary for the administration
and management of the City’s licensing program. Persons or agencies with whom this information may be
shared include:
City personnel, including law enforcement personnel, administering the license program;
The Bureau of Criminal Apprehension;
The City Attorney and support staff of the City Attorney’s office;
Federal, state, local, and contracted private auditors;
Federal and State agencies with oversight or responsibility related to the licensed business;
Those individuals or agencies as to whom you give your express written permission for release of
the information.
Unless otherwise authorized by state statute or federal law, other governmental agencies utilizing the
reported private data must also treat the information as private.
You may wish to exercise your rights as contained in the Minnesota Government Data Practices Act. These
rights include:
The right to see and obtain copies of data maintained about you;
The right to be told the contents and meaning of the data; and
The right to contest the accuracy and completeness of the data.
To exercise these rights, contact the Farmington Human Resources Director at 430 Third Street,
Farmington, MN 55024 (651) 280-6800. I have read and I understand the above information regarding my
rights as a subject of government data.
___________________________________________ _______________________
Applicant Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

GamblingEventPermit2019Fillable City of Farmington

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document