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LG220 Application for Exempt Permit 8/14Page2of2 Local Unit of Government Acknowledgment CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township HThe application is acknowledged with no waiting period. ::The application is acknowledged with no waiting period. The application is acknowledged with a 30-day waiting u he application is acknowledged with a 30-day waiting period, and allows the Board to issue a permit after 30 days I period, and allows the Board to issue a permit after 60 days for a 1st class city). 30 days. The application is denied. he application is denied. Print City Name: Arden HIIIS Print County Name: Signature of City Personnel: Signature of County Personnel: Title: Date:Title: Date: TOWNSHIP (if required by the county). On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. (A township has no statutory authority to approve or Local unit of government must sign. deny an application, per Minn. Statutes, section 349.166.) Print Township Name: Signature of Township Officer: Title: Date: Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned to t nL_4 within 30 days of the event date. JlChiefExecutiveOfficer's Signature: Date: Print Name: Bonnie Westberg Requirements Complete a separate application for: Financial report and recordkeeping required. all gambling conducted on two or more consecutive days, or A financial report form and instructions will be sent with your all gambling conducted on one day.permit, or use the online fill-in form available at Only one application is required if one or more raffle drawings are www.mn.gov/gcb. conducted on the same day. Within 30 days of the event date, complete and return the Send application with: financial report form to the Gambling Control Board. Your a copy of your proof of nonprofit status, and organization must keep all exempt raffle records and reports for application fee (nonrefundable). If the application is 3-1/2 years (Minn. Statutes, section 349.166, subd. 2(f)). postmarked or received 30 days or more before the event, the application fee is $50; otherwise the fee is $100. Make Questions? check payable to State of Minnesota. Call the Licensing Section of the Gambling Control Board at 651-539-1900. To: Gambling Control Board This form will be made available in alternative format (i.e. large1711WestCountyRoadB, Suite 300 South print, Braille) upon request.Roseville, MN 55113 Data privacy notice: The information requested application. Your organization's name and ment of Public Safety;Attorney General; on this form(and any attachments)will be used address will be public information when received Commissioners of Administration, Minnesota by the Gambling Control Board (Board)to by the Board. All other information provided will Management&Budget,and Revenue; Legislative determine your organization's qualifications to be private data about your organization until the Auditor, national and international gambling be involved in lawful gambling activities in Board issues the permit. When the Board issues regulatory agencies; anyone pursuant to court Minnesota. Your organization has the right to the permit,all information provided will become order; other individuals and agencies specifically refuse to supply the information; however, if public. If the Board does not issue a permit,all authorized by state or federal law to have access your organization refuses to supply this information provided remains private,with the to the information; individuals and agencies for information,the Board may not be able to exception of your organization's name and which law or legal order authorizes a new use or determine your organization's qualifications and, address which will remain public. Private data sharing of information after this notice was as a consequence, may refuse to issue a permit. about your organization are available to Board given; and anyone with your written consent. If your organization supplies the information members, Board staff whose work requires requested,the Board will be able to process the access to the information; Minnesota's Depart-