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LG220 Application for Exempt Permit <br />11/17 <br />Page 2 of 2 <br />LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to <br />the Minnesota Gambling Control Board) <br />CITY APPROVAL <br />COUNTY APPROVAL <br />for a gambling premises <br />for a gambling premises <br />located within city limits <br />located in a township <br />HThe application is acknowledged with no waiting period. <br />he application is acknowledged with no waiting period. <br />The application is acknowledged with a 30-day waiting <br />he application is acknowledged with a 30-day waiting <br />period, and allows the Board to issue a permit after 30 days <br />period, and allows the Board to issue a permit after <br />(60 days for a 1st class city). <br />30 days. <br />The application is denied. <br />❑The application is denied. <br />Print City Name: <br />Print County Name: <br />Signature of City Personnel: <br />Signature of County Personnel: <br />Title: Date: <br />Title: Date: <br />TOWNSHIP (if required by the county) <br />On behalf of the township, I acknowledge that the organization <br />is applying for exempted gambling activity within the township <br />limits. (A township has no statutory authority to approve or <br />The city or county must sign before <br />deny an application, per Minn. Statutes, section 349.213.) <br />submitting application to the <br />Print Township Name: <br />Gambling Control Board. <br />Signature of Township Officer: <br />Title: Date: <br />CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) <br />The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial <br />report will be completed and returned to the Board within 30 ys of vent date. <br />J <br />Chief Executive Officer's Signature: Date: pf'ir/�f✓�/ <br />(Signature st b EO's sign to ; designee may not sign) <br />Print Name: Fr. Gregory L Esty <br />REQUIREMENTS <br />MAIL APPLICATION AND ATTACHMENTS <br />Complete a separate application for: <br />Mail application with: <br />• all gambling conducted on two or more consecutive days; or <br />a copy of your proof of nonprofit status; and <br />• all gambling conducted on one day. <br />application fee (non-refundable). If the application is <br />Only one application is required if one or more raffle drawings are <br />postmarked or received 30 days or more before the event, <br />conducted on the same day. <br />the application fee is $100; otherwise the fee is $150. <br />Financial report to be completed within 30 days after the <br />Make check payable to State of Minnesota. <br />gambling activity is done: <br />To: Minnesota Gambling Control Board <br />A financial report form will be mailed with your permit. Complete <br />1711 West County Road B. Suite 300 South <br />and return the financial report form to the Gambling Control <br />Roseville, MN 55113 <br />Board. <br />Questions? <br />Your organization must keep all exempt records and reports for <br />Call the Licensing Section of the Gambling Control Board at <br />3-1/2 years (Minn. Statutes, section 349.166, subd. 2(f)). <br />651-539-1900. <br />Data privacy notice: The information requested <br />application. Your organization's name and <br />ment of Public Safety; Attorney General; <br />This form will be made available in alternative format (i.e. large print, braille) upon request. <br />An equal opportunity employer <br />