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Organization Name_ Local Unit of Government Acknowledgment If the gambling promises 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. 27 Page 2 of 2 11/04 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 applic Check the action tha/witthono the county is taking on this ap The county approves the applica' waiting period. /1 f p The city approves the application with a 30 day 3 waiting period, and allows the Board to issue a El The county approves the pplication with a 30 day permit after 30 days (60 days for a first class waiting period, and ally s the Board to issue a city), permit after 30 days. El The city denies the ap�Jpplliiication. The county den's the application. Print name of city; _Y Ln�'�(.1, --�-----_. Print name ofc nt, _ receiving county personnel receiving application Title TOWNSHIP: On behalf of tho township, I ackno'mledge the organization is applying for exempted gamLling activif. within the township limits. [A township hasng sh story authority to approve or deny an applicatio (Minnesota Statute 349.213, subd. Print name of township_ Signature of application Chief Executive Officer's Signature The information provided in this application its complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and ret ured1byhe Gar ling ntro))/Bo tl. ,within .30 days of the date of our gambling activity.-- Chief executive officers signature �, /. 1\� p. d....,i Name (please 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 Date1?_/ �� / G.Y 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