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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, the city must sign this application. If the gambling premises is located in a township, both the county and township must sign this application. Check ('1) the action that the city is taking on this application. __The application is acknowledged with no waiting period __The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a 1st class city). ___The application is denied. Print city name __ _,- _ - __.__.__ - - -- On behalf of the city, I acknowledge this application. Signature of city personnel receiving application ______________ - --- — Title Date / / Check this application. ____The application ____The application period, days. The application ('1) the action that the county is taking on is acknowledged with no waiting period. is acknowledged with a 30 day waiting and allows the Board to issue a permit after 30 is denied. name _____. _ the county, I acknowledge this application. county personnel receiving application __ Print county On behalf of Signature of Title Date / / TOWNSHIP: organization township limits. or deny an application Print township On behalf of the township, l acknowledge that the is applying for exempted gambling activity within the (A township has no statutory authority to approve [Minnesota Statute 349.213, subd. 2)) 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. I acknowledge that the financial report will be completed and returned Jo the Board within 30 days of the date of our gambling activity. � c L> - Chiefexecutiveofficer'ssignature c. Z.L .� (c .._,l Date 1 / k 1,71{J� Complete an application for each ga bing activity:f • one day of gambling activity • two or more consecutive days of gambling activity • each day a raffle drawing is held Send application with: • a copy of your proof of nonprofit status, and • $50 application fee for each event. Make check payable to "State of Minnesota:' To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Financial report and recordkeeping required A financial report form and instructions will be sent with your permit. Within 30 days of the activity date, complete and return the financial report form to the Gambling Control Board. questions? Call the Licensing Section of the Gambling Control Board at 651- 639 -4076. Data privacy. This form will be made available in altemative format (I.e. large print, Braille) upon request. The information requested on This form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will be able to process your application. Your name and and your organization's name and address will be public information when received by the Board. All the other information you provide will be private data until the Board issues your permit. When the Board issues your permit, all of the information provided to the Board will become public. If the Board does not issue a permit, all information provided remains private, with the exception of your name and your organization's name and address which will remain public. Private data are available to: Board members, 3 Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; LegislativeAuditor, 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 authorizes a new use or sharing of information after This Notice was given; and anyone with your consent.