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fV,1 1.J .�VCJJ li U�J <br />L JVfll .0 VJ1G_�J"V I J <br />L0220 Application for Exempt Permit <br />Organization Name <br />Local Unit of Government Acknowledgment <br />Page 2 of 2 <br />lithe gambling premises is within city limits, the <br />City must sign thls application. <br />On behalf of the city, I acknowledge this application. <br />Check the action that <br />the city is taking on this application, <br />®The city approves the application with no <br />waiting period. <br />The city approves the application with a 30 day <br />waiting and allows the Board to Issue <br />period, a <br />permit after 30 days (60 days for a first class <br />city). <br />. The city denies the application. <br />Print name of city <br />(Signature of city personnel racsiving application) <br />Tlda <br />Date / / <br />Chief Executive Officer's Signature <br />The information provided in this application is compl <br />Chief executive officer's signat <br />06/03 <br />if the gambling premises Is located In a township, both <br />the county and township must sign this application. <br />On behalf of the county, I acknowledge this application. <br />Check the action that <br />the county Is taking on this application. <br />ri The county approves the application with no <br />wailing period. <br />O The county approves the application with a 30 day <br />waling period, and allows the Board to Issue a <br />permit afler 30 days. <br />O The county denies the application. <br />Print nama of county <br />(Signature] of county personnel receiving application) <br />Title <br />Oats J <br />TOW NSkIIP: On behalf of the township, I acknowledge that <br />the organization is applying for exempted gambling activity <br />within the township limits. iAtownship has no statutory <br />authorityto approve or deny an application (Minn. Stat. sec. <br />349.213, cubd. 2).) <br />Print name of township <br />(Signature of township official acknowledging application) <br />Title <br />Date <br />and accu 'ate to the hest of my knowledge. <br />h. <br />Name (please print) e63t F1'[, rr 1c-1G <br />Date . /j / <br />Mail Application and Attachments <br />At least 45 days prior to your scheduled activity date send: <br />• the completed application, <br />• a copy of your proof of nonprofit status, and <br />• a check for $50. Make check payable to "State of Minnesota ". <br />Application fees are not prorated, refundable, or transferable. <br />Send to: <br />Gambling Control Board <br />1711 West County Road 9, Suite 300 South <br />Roseville, MN 55113 <br />If your application has not <br />been acknowledged by the <br />local unit of government or <br />hea been denied, do not <br />send the application to the <br />Gambling Control Board <br />