Laserfiche WebLink
• <br />• <br />• <br />LG220 Application for Exempt Permit <br />Page 2 of 2 <br />web 6/03 <br />Organization Name <br />Local Unit of Government Acknowledgment <br />If the gambling premises is within city limits, the <br />city must sign this application. <br />On <br />❑The <br />Print <br />behalf of the city, I acknowledge this application. <br />Check the action that <br />the city is taking on this application. <br />The city approves the application with no <br />waiting period. <br />city approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city). <br />The city denies the application. <br />name of city <br />(Signature <br />Title <br />Date <br />of city personnel receiving application) <br />/ / <br />If the gambling premises is located in a township, both <br />the county and township must sign this application. <br />On behalf of the county, I acknowledge this application. <br />Check the action that <br />the county is taking on this application. <br />DThe county approves the application with no <br />waiting period. <br />The county approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days. <br />The county denies the application. <br />Print name of county <br />(Signature of county personnel receiving application) <br />Title <br />Date ( / <br />TOWNSHIP: On behalf of the township, I acknowledge that <br />the organization is applying for exempted gambling activity <br />within the township limits. [A township has no statutory <br />authority to approve or deny an application (Minn. Stat. sec. <br />349.213, subd. 2).] <br />Print name of township <br />(Signature of township official acknowledging application) <br />Title <br />Date / / <br />u <br />Chief Executive Officer's Signature <br />The information provided in this applicati mpJete and accurate to the best of my knowledge. <br />Chief executive officer's signature <br />Name (please print) <br />Date /0 / /03 <br />Mail Application and Attachments <br />At least 45 days prior to your scheduled activity date send: <br />• the completed application, <br />• a copy of your proof of nonprofit status, and <br />• a check for $50. Make check payable to "State of Minnesota ". <br />Application fees are not prorated, refundable, or transferable. <br />Send to: <br />Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />