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LG220 Application for Exempt Permit Page2of2 7/os LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the gambling premises is located in a township, a a city official must check the action that the city is county official must check the action that the county is taking taking on this application and sign the application. on this application and sign the application. A township official is not required to sign the 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). days. _The application is denied. _The application is denied. Print county name Print city name On behalfofthe county, I acknowledge this application. On behalfof the city, I acknowledge this application. Signature of county official receiving application Signature of city official receiving application Title Date / / (Optional) TOWNSHIP: On behalfofthe township, I Title Date / / acknowledge that the organization is applying for exempted gambling activity within township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349.166)] 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 ret~~u''r??ned to t~~hjje Board within 30 days of the date of ourgambling activity. Chief executive officer's signature ,d{Q~., , d/c~' /'>.~tti.~-~-~' Date U$-Z6 -o q Complete a separate application for each gambing activity: Financial report and recordkeeping required - one day of gambling activity, A financial report form and instructions will be sent with -two or more consecutive days of gambling activity, your permit, or use the online fill-inform available at - each day a raffle drawing is held www.gcb.state,mn.us. Within 30 days of the activity date, Send application with: complete and return the financial report form to the - a copy of your proof of nonprofit status, and Gambling Control Board. -application fee for each event. Questions? Make check payable to "State of Minnesota." Call the Licensing Section of the Gambling Control To: Gambling Control Board Board at 651-639-4076. 1711 West County Road B, Suite 300 South Roseville, MN 55113 Print Form Reset Form Data privacy. Tlris form will be made available the Board will be able to process your Board staff whose work requires access to the in alternative format (i.e. large print, Braille) application. Your name and and your information; Minnesota's Department of Public upon request. The information requested on organization's name and address will be public Safey; Attorney General; Commissioners of this form (and any attachments) will be used by information when received by the Board. All Administration, Finance, and Revenue; the Gambling Control Board (Board) to the other information you provide will be private Legislative Auditor, national and international determine your qualifcations to be involved in data until the Board issues your permit. Vvhen gambling regulatory agencies; anyone pursuant lawful gambling activities in Minnesota. You the Board issues your permit, all of the to court order; other individuals and agencies have the right to refuse to supply the information provided to the Hoard will become that are specifcally authorized by state or information requested; however, if you refuse to Public. If the Board does not issue a permit, all federal law to have access to the information; supply this information, the Board may not be information provided remains private, with the individuals and agencies for which law or legal able to determine your qualifications and, as a exception of your name and your organization's order authorizes a new use or shadng of consequence, may refuse to issue you a permit. name and address which will remain public. information after this Notice was given; and If you supply the information requested, Private data are available to: Board members, anyone with your consent.