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ICocall' Unit iaf Government: JunisdictionT{. Is this gambling premises located within city limits9Q Yes If Yes, write the name of the City: City Name If No, write the name of the County and the Township: County Name Township Name Check the appropriate status of the Township: = organised. Q unorgani'ed Q unincorporated_ Q No 1. The city must sign this application if the gambling premises is within city limits. 2_ The county and township must sign this applica- tion if the gambling premises is notwithin 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 lst class) from the date the, local unit of government • signed the application; provided the application is complete and all necessary information• has been received, unless the local. unit of. government 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. , Crtyor County Acimowiedgment of Receipt of Application Signatyre of person receiving application Date Received: /, — 1._9 Township Acimowledgment of Awareness of _ Application - Signature of person acknowledging application Date Signed: Title of person acknowledging application hie' Ekecutive Officer 1 have read this application and all information is true, accurate and complete. Date: 13c, / -97 ubmit the application at least 45 days prior to your scheduled date of activity. 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 B Suite 300S Roseville, MN 55113 This publication will be made available in altemative format (Le. large print, braille) upon request. Questions an this -form -should-be directed to. the..Ucensing Section of the - Gambling Control Board at (612)639 -4000. Hearing impaired individuals using a TDD 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 (GCS) to determine your compliance with Minnesota Statues and rules goveming lawful gambling activities. All of the information that you supply on this form will became puh + +n information when received by the GCB. Page 9