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• Application for Exempt Permit - LG220 Organization Name Local Unit of Government Acknowledgment Page 2 of 2 8/00 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 aiting 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 LINO Lt ( I2JL Vci 1 UATAI (Signa re of city personnel receiving application) Title i 41 _2 Date _/J u / a' 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 (Minn. Stat. sec. 349.213, subd. 2).] Print name of township (Signature of township official acknowledging application) Title Date Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge. Chief executive officer's signature CG Name (please print) `r 1 M o Y pA_o_g, I N Date / _/? g9/ g9/_q[[ _ Mail Application and Attachments 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 government or has been denied, do not send the application to the Gambling Control Board.