Laserfiche WebLink
LG220 Application for Exempt Permit <br />Organization Norris : )/ _LYI Y )_OF) w_ V <br />Local Unit of GovernmentAcknowled Ment <br />If the gambling premises is within city limits, the <br />city must sign this application. <br />On behalf of the city. I acknowledge this application <br />Check the action that <br />the city is taking on this application. <br />rhe city approves the application with no <br />waiting period. <br />Page 2 of 2 <br />11/04 <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 />rhe county approves the application with no <br />waiting period. <br />The city approves the application with a 30 day I rhe county approves the application with a 30 day <br />waiting period, and allows the Board to issue a waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class permit after 30 days. <br />city). <br />0 T he city denies the application. <br />Print name of city <br />of city personnel receiving application <br />Date <br />ElThe county denies the application. <br />Print name of county <br />of county personnel receiving application <br />Title <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 <br />(Minnesota Statute 349.213, subd. 2).] <br />Print name of <br />Signature of township official acknowledging application <br />Chief Executive Officer's Signature <br />The information provided in this application &complete and accivate to the best of my knowledge, I acknowledge that the <br />financial report will be completed and returned to the Gamb}i1IQ Con of Board whb!p 3'0 ays of the date of our gambling <br />activity. - ..... % <br />Chief executive officer's sianature�.:'Gtl;l,. ! sl�-> <br />Name (please <br />Mail application and attachments <br />Complete an application for each <br />gambling activity: <br />• one day of gambling activity <br />• two or more consecutive days of <br />gambling activity <br />• each day a raffle drawing is held <br />Date /-1?- / <br />Send: <br />• the completed application, <br />• a copy of your proof of nonprofit status (see instructions), and <br />a $50 application fee. Make check payable to "State of Minnesota". <br />To: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />+W <br />