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L6220 Application ffor Exempt Permit LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required #>�fore submitting a f(cation u�i, Page 2 of 2 the Minnesota Gambling Control Board) 9 PP to CITY APPROVAL for a gambling premisesTnod COUNTY APPROVAL located within city limits�' d gambling Premises The application is acknowledged with no wain WcOWd in a township application is acknowledged with no waking The application is acknowledged with a 30-day wpew Period, and allows the Board to issue a permit aftication is a�wledged with a 30-day waiting (60 days for a 1st class city). nd allows theBoard to issue a. Permit after The application is denied.Print City Name: CEO+ of Hu�C p cation is denied - Print - - - - - - - Print County Name: -- Signature of City Personnel /� Signature of County Personnel: Title: —CC C1 Date:- 3 Z - - emu% U Title: Date:_ TOWMMIP (if required by the county) - - - - - on behalf of the township, I acknowledge that the organization The city or county must sign before is applying o hi rxempted gambling activity within the township limits' P statutory authority to approve or submitting application to the deny an application, per Minn. Statutes, section 349.213.) fGambling Control Board. Print Township Name: Signature of Township Officer; ` - - Title: _---------� CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) _ Date: The information provided in this application is complete and accurate lb,the nest of my knowledge, I acknowledge that the financial report will be completed and returned td the Board within 30 days of t}r� eves date. Chief Executive Officer's Signature: (Signatur must be CEOssign atur�; tijmee may oar9n) Date: 31�020 Print Name: Stephanie Peterson REQUIREMENTS MAIL APPLICATION AND ATTACHME complete a separate application loran NTS • all gambling conducted on two or more consecutive days; or Mail application wiiifn • all gambling conducted on one day, a copy of Your of nonprofit stains; and Only one application Is required if one or more raffle drawings are application fee (r�n-refundable). If the application is conducted on the same day. Postmarked or received 30 days or more before the event, Financial report to be completed within 30 d the application fee is $100; otherwise the fee is $150, gambillng activity is done: aYs after the Make check payable to State of Minnesota. A financial report form will be mailed with your permit. complete TO: Minnesota Gambling Control Board and return the financial report form to the Gambling Control 1711 West County Road B, Suite 300 South Board. Roseville, MN 55113 Your organization must keep all exempt records and reports for questions?3-1/2 years (Minn. Statutes, section 349.166, subd. 2 Can the ticenstng Section of the Gambling Control Board at (�)- 651-539-1900. Data privacy notice: The information requested application, on this form Your liand any attachments) will be used address will be PublicInformationInformation when received merit of Public 5a nization's name and by the Gambling Control Board Board to �% Attorney General; determine your arganizatiori's qualifications to b the Board. Commissioners of Administration, Minnesota about rnfiurmaniza provided will Management & Budget, and Revenue; Leglsiative be involved in lawful gambling activities in tlour organization until me Au�ar, national and international gambling Minnesota. Your Board issues the permit, When fire Board issues refuse to supply the organization howeverigr, if pu permit, an inforrrra€ion provided will beo:theavr� order; OMeragndividu s and agencies to court Your organization refuses to supply this l�nforrti�rratlan Board does not issue a permit, all authorised by state or federal law to the ace information, the Board may not be able to °�� remain private, with the to the ized by slat individuals and agencies for determine your organization s qualifications and, exception i your argaain Public name and Mich taw ar legal order authorizes a new use or as a consequence, may refuse to issue a address which wilt rerrein public Private data If our organization permit' about Your Organization are available to Board sha€ ng of Warntation after this notice was y d, supplies the information members,Board staff given; and anyone with your written consent. requested, the Board will be able to process the access to the in whose work requires formation: M#irresota's Depart- - This form coil! be made available in alternative format (i.e. large print, braille) upon request An a-1 ° ity employer