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, Or behalf of tiha city, I acknowledge this application. Check the action that the city Is taking on this application. iDThe city approves the application with no —1 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 tha application. Print name of city (Signature of city personnel receMng application) Title Date / / Page 2 oft 08103 If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, f acknowledge this application. Check the action that tha county Is taking on this application. rlThe county approves the application with no waiting period. O The county approves the application with a 30 day waling 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 Data J Chief Executive Officer's Signature The information provided In thjsappl' Lion is c plete •n. aocutate tQthe best of my knowledge. Chief execute officers signature �' ¢ i' �,_ t. pate Fr i Rld1 TOWN$HIPI On behalf cf the township, I acknowledge that the organization is applying for ezempted gambling activity within the township limits. (A township has no statutory authority lo approve or deny an application (Minn, Stat. sec. 349213, ;tube. 2).] Print name of township (Spann. of township official acknowledging application) Title_ Date ! ! Name (please print) ` <o13,=(21 'T, f 17 z ?ATP, Mali Application and Attachments At least 45 days prior to your scheduled activity data sand: • the completed application, • a copy of your proof of nonprofit status, and • e 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 byte local unit of gavemment or has been denied, do not send the application to the Gambling Control Board.