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C Hi' ( :) la -Cc H Local Unit of Government Jurisdiction Is this gambling premises located, within city limits ?' Yes C No -..If._Yes, write the name of the City: City Name Li rru5 CAAJADA, If No, write the name of the County and the Township: County Name Township Name Check the appropriate status of the Township: Q organized Q unorganized 'R AUG 1988 cAMBt1NG t RC COPttRO , L ix3cr3_sorated l ocal i if `OftaVeri meat Acknowleiignrent .„)._,The city taust sign this application if the gambling ,_. 4 premises is within city limits. 2. The county and township must sign this applica- tion if the gambling premises is not within city limits. 3. DO NOT submit this application to the Gambling Control Board if it is denied by the local unit of government. 4. NOTE: A Township may not deny an application. Upon submission of this application to the Gambling Control Board, the exemption will be issued not more than 30 days (60 days for cities of the 1st class) from the date the local unit of govemment signed the application, provided the application is complete and all necessary information has been received, unless the local unit of govemment passes a resolution to specifically prohibit the activity. A copy of that resolution must be received by the Gambling Control Board within 30 days of the date filled in below. Cities of the first class have 60 days in which to disallow the activity. City or County Acknowledgment of Receipt of Application Signatur ofperson receiving application /, Date Recei4ed: Title person receiving application Township Acknowledgment of Awareness of Application Signature of person acknowledging application Date Signed: Title of person acknowledging application Oath of Chief Executive Officer I have read this application and ail information is true, accurate and complete. QZ"—cic 2:74 2 A. 77_,-- zre-,e---- / / Submit the�dppilation at (east 45 days prior to your scheduled date of activity. i Be sure to attach the $25 application fee and a copy of your proof of nonprofit status. Mail the complete application and attachments to: Gambling Control Board 1711 W. County Rd 9 Suite 300S • Roseville, MN 55113 This publication will be made available in alternative format (i.e. large print, braille) upon request. Questions on this form should be directed to the Licensing Section of the Gambling Control Board at (612)6394000. Hearing impaired individuals using a TOO may call the Minnesota Relay Service at 1- 800-627 -3529 in the Greater Minnesota Area or 297 -5353 in the Metro Area. The information requested on this form will be used by the Gambling Control Board (GCB) to determine your compliance with Minnesota Statues and rules governing lawful gambling activities. AI! of the information • tat you supply on this form will become ^^ .n eceived by the GCB. Page 5 Date: cr/z.