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HUI 13- r 1U3 11 ' tJ ✓J uHtnL11VU LUIY KUL bUHKU LG220 Application for Exempt Permit Organization Name Local Unit of Government Acknowledgment bJ1b.174UY.i Y. U3 /U�� Page 2of2 08 /03 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. I-1 The city approves the application with no is-! 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 fora first class city). . The city denies the application. Print name of city (Signature of city personnel receiving application) mle Date / Chief Executive Officer's Signature The information provided in this . • •' .lion is complete Chief executive officer's signa If the gambling premises 1s 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 wailing period, 0 The county approves the application with a 30 day waling period, and allows the Board to Issue a permit after 30 days. j'j The county denies the application. Print nama of county ( Signatun, 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. [Atownship has no statutory authority le epprove or deny an application (Minn. Etat. sec. 349.213, ;sift. 2).] Print name of township (Signature of township official acknowledging application) Title_ Date / / SMARM aocu .ate to a best of my knowledge. 1Z•l4 r-j Name (please print) fSb�t =f2-C cr. Fort Mail Application and Attachments At least 45 days prior to your scheduled activity date send: • the completed application, • a copy of your proof of nonprofit status, and • a check for $50, Make check payable to "State of Minnesota ". Application fees ars not prorated, refundable, or transferable. Sand to Gambling Control Board 1711 West County Road El, Suite 300 South Roseville, MN 55113 Date 8 /'4 I cjt 11 your application has not been acknowledged by the local unit of government or has been denied, do not send the application to the Gambling Control Board.