10/10/2005 Council Packet - Laserfiche WebLink

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LG220 Application for Exempt Permit Organization Name Page 2 of 2 11/04 Local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I acknowledge this application. Check the action that the city is taking on this application. ®The city approves the application with no waiting period. ❑ The city approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city). The city denies the application. Print name of city Signature of city personnel receiving application Title Date / / If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county is taking on this application. ®The county approves the application with no waiting period. ▪ The county approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days. ® The county denies the application. Print name of county Signature of county personnel receiving application Title Date ! / TOWNSHIP: On behalf of the township, I 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 (Minnesota Statute 349.213, subd. 2).] Print name of township Signature of township official acknowledging application Title Date 1 / Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and r rff d. to tl}e Gambling Control Board within 30 days of the date of our gambling activity. Chief executive officer's signature Name (please print) T i Th a H y .1 ` 4/0g_ Date ? // /05— Mail application and attachments Complete an application for each gambling activity: • one day of gambling activity • two or more consecutive days of gambling activity • each day a raffle drawing is held Send: • the completed application, • a copy of your proof of nonprofit status (see instructions), and • a $50 application fee. Make check payable to "State of Minnesota ". To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113