08-27-2003 Council Agenda - Laserfiche WebLink

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LG220 Application for Exempt Permit Organization Name Local Unit of Government Acknowledgment 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, D L!The city approves the application with no waiting period. ig The pity 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 clan city). ii The city denies the application. Print name of city (Signature of city personnel racsiving application) lido Date / / Page 2 of 2 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, I acknowledge this application. Check the action that the county Is taking on this application. rl ❑ The county approves the application with no waiting period. O The county approves the application with a 30 day wal :ing period, and allows the Board to Issue a permit after 30 days. O The county denies the application. Print nama of county (Signature of county personnel receiving application) Title Date J TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity withinthetownship!imlts. [Atownship has no statutory, authority to approve or deny an application (Minn. Stat. eec. 349213, ;iubd. 2).) Print name of township (Signature of township official acknowledging application) Title_ Date / I Chief Executive Officer's Signature The information provided in this application is complete and =rata to Chief executive officer's signature e n Name (please print) -Ro6∎-r &! C3 FiT'Ztin,C -- Mali 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 • e cheek 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 best of my knowledge. r Data If your application has not been acknowledged byte local unit of government or has been denied, do not send the application to the Gambling Control Board.