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LG220 Application for Exempt Permit Page 2 of 2 6/08 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the amblin g g premises is located in a township, both the city must sign this application. the county and township must sign this application. Check (1~~ the action that the city is taking on Check (11~ the action that the county is taking on this application. this application. _ The application is acknowledged with no waiting period. ____The application is acknowledged with no waiting period. ___The application is acknowledged with a 30 day waiting ----The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 days (60 days fora 1st class city). __The application is denied. _ _The application// is de1nied. ~J~ Print city name L= !_~l /Z`'_._ ~~[J~(%f%7=________ Print county name On behalf of the county, I acknowledge this application. Signature of county personnel receiving application On beha!( f the city, I ackno ledge this application. Sig atur of c'ty ersonnel r 'vu application ~~--p~ Title-----------------------Date-----t-----/------ Titlel=/7_S~ ~,~~~__Date_~_/~~/_~~_O/ TOWNSHIP: On behalfofthe township,lacknowledge thatthe / organization is applying for exempted gambling activity within the township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349.213, subd. 2)] Print township name Signature of township official acknowledging application Title----------------------Date CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application is complete and accurate to the best of my knowledge. 1 acknowledge that the financial report will be completed and returned o the Board within 30 days of the date of our gambling activity. ~ , - Chiefexecutiveofficer'ssignature _ c-~ Date_~/__~l ' Complete an application for each ga ' bing activity: Financial report and recordkeeping • one day of gambling activity required • two or more consecutive days of gambling activity A financial report form and instructions will be • each day a raffle drawing is held sent with your permit. Within 30 days of the Send application with: activity date, complete and return the financial • a copy of your proof of nonprofit status, and report form to the Gambling Control Board. $50 application fee for each event. questions? Make check payable to "State of Minnesota" Call the Licensing Section of the Gambling To: Gambling Control Board Control Board at 651-639-4076. 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy. This form will be made available the Board will be able to process your Board staff whose work requires access to in attemative fornat (i.e. large print, Braille) upon application. Your name and and your the information; Minnesota's Department of request. The information requested on this organization's name and address will be public Public Safety; Attorney General; Commissioners form (and any attachments) will be used by the information when received by the Board. All of Administration, Finance, and Revenue; Gambling Control Board (Board) to determine the other information you provide will be private Legislative Auditor, nalionaland international your qualifications to be involved in lawful data until the Board issues your permit. When gambling regulatory agencies; anyone pursuant gambling activities in Minnesota. You have the the Board issues your permit, all of the to court order; other individuals and agencies right to refuse to supply the information information provided to the Board will become that are specifically authorized by slate or requested; however, iF you refuse to supply public. If the Board does not issue a permit, all federal law to have access to the information; this information, the Board may not be able to information provided remains pdvate, with the individuals and agencies for which law or legal determine your qualificafions and, as a exception of your name and your organization's order aulhodzes a new use or sharing of consequence, may refuse to issue you a name and address which will remain public. information after this Notice was given; and permit. If you supply the information requested, Private data are available to: Board members, anyone with your consent.