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LG220 Application for Exempt Permit Organization Name Local Unit of Government Acknowledgment Page 2 of 2 11/04 If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I acknowledge this application. Check the action that the city is taking on this application. ®The city approves the application with no waiting period. ®The city approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city). The city denies the application. Print name of city Signature of city personnel receiving application Title Date / / If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county is taking on this application. ® The county approves the application with no waiting period. ElThe county approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days. The county denies the application. Print name of county Signature of county personnel receiving application Title Date TOWNSHIP: On behalf of the township, I acknowledge that the 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 name of township 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 to the Gambling Control Board within 30 days of the date of our gambling activity. r Chief executive officer's signature �„� 20/ Name (please print) Father David Kohner Date 09 /26 / 06 Mail application and attachments Complete an application for each gambling activity: • one day of gambling activity • two or more consecutive days of gambling activity • each day a raffle drawing is held Send: • the completed application, • a copy of your proof of nonprofit status (see instructions), and • a $50 application fee. Make check payable to "State of Minnesota ". To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113