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Gambling Control Board Fax:651- 639 -4073 Feb 15 '01 15:34 P. U3 <br />Application for Exempt Permit - L0220 Psge 2 2 <br />i3 of <br />Organization Name fOR/fl FR QOWaS OP 4Fk ... Si: PAUL. WI N?rcg GA+ 1 vAL i kr <br />Local Unit of Government Acknowledgment <br />• <br />if the gambling promises is within city Iimits, the <br />city must sign this 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 />n The city approves the application with no <br />I 1 waiting period. <br />❑The city approves the application with a 30 day <br />wailing period, and allows the Board to issue 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 Gry personnel rece'Ning applcation) <br />Tdb <br />Date / / <br />H 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 />nThe county approves the application with no <br />waiting period. <br />❑ The county approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days. <br />ElThe county denies the application. <br />Print name of county <br />(Signature of county personnel receiving application) <br />Trite <br />Data <br />TOWNSHIP: On behalf of the township, l acknowledge that <br />the organization it applying for exempla' gambling activity <br />within the township kmks. [A township has no statutory <br />authority to approve or deny an pppfication (Minn. Stat sec. <br />349.213, subd. 2)] <br />Print name of mvmshp <br />(Signature of township official acknowledging eppication) <br />Tile <br />Date / <br />Chief Executive Officer's Signature <br />The information provided in this a(12si,n. n is complete and accurate to the best of my knowledge. <br />• <br />0 /0, . <br />Name (please print) ett4gMll $J. in • O' Cmo poR Date (g /14L,/ OJ <br />Chief executive officer's signature <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 $25 application fee (make check payable to "State of Minnesota "). <br />Application fees are not prorated, refundable, or transferable. <br />Send to: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />If your application has not <br />been acknowledged bythe <br />local and of government or <br />has been denied, do not <br />send the application to the <br />Gambing Control Board. <br />Page 37 <br />