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P.Arli ILA-- 1141 LM, . •. LG220 Application for Exempt Permit Organization Name Local Unit of Government Acknowledgment Page 2 of 2 If the gambling premises is within clty limits, the city must sign thls application. On behalf of the city, I acknowledge this application. Check the action that the city Is taking on this application. D The city approves the application with no waiting period. ri The city approves the application with a 30 day LJ waiting period, and allows the Board to Issue a permit after 30 days (60 days fora first class city). IN The city denies the application. Print name of city (Signature of city personnel raciaNing application) Title Date / ! _._. _.. ... 06;03 If the gambling premises Is located in a township, both the county and township must sign this application. On behalf of the county, 1 acknowledge this application. Check the action that tha county Is taking on this application. D The county approves the application with no wailing period. 0 The county approves the application with a 30 day wafting period, and allows the Board to Issue a permit after 30 days. The county denies the application. Print nama 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 lo approve or deny an application (Minn. Etat, sec. 349.213, ;iubd. 2).) Print name of township (Signatum of township official acknowledging application) Title Date Chief Executive Officer's Signature The information provided in this a..' --'an is complete Chief executive officer's signatu Name (please print) accu •at to • the best of my knowledge. 2T Date O / 1 ! Mail Application and Attachments At least 45 days prior to your scheduled activity data 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 are not prorated, refundable, or transferable. Send to: Gambling Control Board 1711 West County Road 8, Suite 300 South Roseville, MN 55113 If 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.