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. . . . . Page 2 OT 2 LG220 ApplicatIon fo~Exemft Perrp~t , . / _ . <? ,_ ._~ /1 12/03 ~~::~~'i't :;~ove-;;;-~:;;~~~~i~:~~:-" /n4~r'" ""- "- r <Oed. /C4d~L! C~d~ If the gambling premises is within city limits, the city must sign this application. On ::>ehalf of the city, I ackl~owledgG this application. Check the action that the city is taking on this application. (VI The city approves the i1pplication with no LC:l,I waiting period. O The city approves the application with a 30 day waiting period, and allows the Board to issue a permit efl:er 30 c;ays (60 days for a first class city). o The city denies tile application. (' -- 'US,Jr .,. A. '-J t>. ) P;;R4~ID~- (SlgnatL:rc 0; CI1Y personnel recelvlrlg applicatiOn) Title (' i -IuufJdnll nf S fta-Ir.Y,- --:;-. .. ...............u..u. .u_...n.____.______._.._._. ... ....__.._ Date C~ 1,Q3 f Cd _____..m _._. . ...._................ _...._~__ 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 appiication. Check the action that the county is taking on this application. D The county approves the application with no waiting period. D Th~ .county. approves, the application wi~h a 30 day waiting penod, and clllo'vvs the Board to Issue a permit after 30 days. o The county denies the application. Print name of county ___ (Signature of county personnel receiving applic8tion) Title Oate__.___) __.___1_____ TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted qambling activity within the township limits. [A tovvnship has no statutory authority to approve or deny "m appiication (Minnesota Statute 349.213, su!::ld. 2J.] Print name of township (Signature oftownship officiai aGknowiedging appiicatio'1) Title Oate.___ I .....' Chief Executive Officer's Signature The infoimatio;J provided in this application is complete and accurpte to the best of my knowledge. Chief executive officer's sig natu re:.~~;'-~.t::~-41 4!a..c.{. d""-Z-~:~;LA.~_..___m.m u ___m_.___m.____.____ Name (please print) ..........._mm__f1L,,~k~-c;d::._t.4_ApJ;....kC".:~______________ Oat8___/.:__I__::(_'::- 16~f.._. Mail Application and Attachments At least 45 cays prior to your scheduled activity date send: . the completed application, Co copy of your proof of nonprofit status, and a S50 application fee (rr:ake check payable to "State of Minnesota"). Application fees are not prorated, refundable, or transferable. Send to: if your application has not been acknovvledged by the locai unit of government or I hi1s been denied, do not ' s'~nd the application to the ! Gambling Control Beard I ! Gambling Control Board i 71 i West County Road S, Suite 300 South Roseville. MN 55'113