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Gentling Control Bard Eax:651-639 -4073 <br />4. Application for Cxempttennit -LG220 <br />Organization Nam* M (Al $J r5CT,.. A . c) 9O /G! A lt-c <br />Local Unit of Government Acknowledgment <br />Nov 15 "10 10:$ <br />If the gambling premises Is within city limits. the <br />alty must sign this application: <br />On behalf of the city, I acknowledge this application. <br />Check the action that <br />the city b tatting on (bit applloatlon. <br />CDThe city approves the application with no <br />waiting period. <br />❑ <br />The city approves the application with a 30 day <br />waiting period, and album the Board to issue a <br />permit after 30 day; (50 days fora first class <br />City), <br />0 The city denies the apptatWn. <br />Li Mitt- dvv,9,41. <br />(Signature of cttnonnHd�receiving <br />Tbe ,, <br />on // 070, 069 <br />P. 07 <br />Pugs 4 012 <br />0/00 <br />If she gambling premises Is boated In a township, both <br />the county end township must sign this application. <br />On behalf of the county,1 acknowledge this application. <br />Cheek t a action that <br />the county le Sides on this application. <br />0 oupntf prove* the application with no <br />0 The ebunty appro es the eopGdation with a 30 day <br />waiting pined, and *saws the ®garu t0 laud it <br />permit alter 30 days. <br />0 The count/ denies the applicatbn. <br />Print name of county <br />(Signature of county personnel ncarvYng application) <br />Yea <br />Dare <br />TOWNSHIP:. On Dana of be townthip, t aeknowledua that <br />She arganlutbn emptying forexempted gambling aottiiy <br />within be township bulb. (A township has no Mutiny <br />oudlor*y to "Prove or dent tin apptitwrton (Minn. Stet, sae <br />349.213, subd.2).j <br />Print name of/owns/Pp <br />(signature of towns* medal acknowledging app$aaton) <br />ties <br />oats <br />Chief Executive Officer's Signature • <br />The information provided in this application is complete a/ntl accurate tit tin) best of my knowledge, <br />Chief epacutrvm ofcVs signature <br />Name (please print) 1v at. N Gy <br />Date <br />OA <br />Mail Application and Attachments <br />At least 45 days prior to your scheduled act%*y date send: <br />• trio completed application, <br />• a copy of your proof of nonprofit status, and <br />• a $25 application fee (manta check payable to "State of Minnesota•). <br />Application fees are net prorated, refundable, or transfarabla. <br />Send to: Gambling control Board <br />1711 West County Road 8, Suite 340 South <br />Roseville. MN 55113 <br />EB E9tld -Wild() 3 <br />Page 12 <br />It your spplication has not <br />been acknowledged by the <br />local unit of government or <br />has been denied, do not <br />sand the *ppi(p%on to the <br />Gambling Control Board, <br />9bL65ZSZT9 0E :b0 0002 /0Z /TT <br />