01-14-1999 Council Agenda - Laserfiche WebLink

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Application for Exempt Permit - LG220 Page 2 of 2 3/98 Organization Name Local Unit of Government Acknowledgment (R lithe;; gambling,premises- is`within city limits;the: c(ty P111 .gn.thi applicaLom.. On behalf of the city, I acknowledge this application and three options for the city: 1. Approve the application: By taking no action, the city allows the Board to issue a permit after 30 days (60 days for a first class city). 2. Waive the above -noted waiting period: The city allows the Board to issue a permit before 30 days (60 days for a first class city). Docu- mentation attached. 3. Deny the application by passing a resolution within 30 days (60 days for a first.class city). Print nam of city: /—/ �/e. &./(//9 4 (Signatur/e of c personnel receiving application) Title /�2- G( (c.l _ (?0_-/.17) Date /,.n l /,5' / Executive Officer's Signature IVthe gamblingipremises.is- located in -a township, both;r the county and township must sign this application On behalf of the county, I acknowledge this application and three options for the county: 1. Approve the application: By taking no action, the county allows the Board to issue a permit after 30 days. 2. Waive the above -noted waiting period: The county allows the Board to issue a permit before 30 days. Documentation attached. 3. Deny the application by passing a resolution within 30 days. Print name of county: (Signature of county personnel receiving application) Title Date / / On behalf of the township, 1 acknowledge that the organization is applying for exempted gambling activity within the township limits. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). Print name of township: (Signature of township official acknowledging application) Title Date / / The information provided in thh_. _ ;ation is comp and acc (rate to the best of my knowledge. 1` • Chief Executive Officers sig Name (please print) 4of3 ?(Z7 Z - \-- I cL Date / Z / 11 / Mail Application and Attachment(s) At least 45 days prior to your scheduled activity date send: • the completed application; • a copy of your proof of nonprofit status, and • a $25 application fee (make check payable to "State of Minnesota "). Application fees are not prorated, refundable, or transferable. Send to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 If your application has not been acknowledged by the local unit of govemment, do not send the application to the Gambling Control Board. Page 13