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5/15 LG220 Application for Exempt Permit Page 2 of 2 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to the Minnesota Gambling Control Board) CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township The application is acknowledged with no waiting period. ___The application is acknowledged with no waiting period. The application is acknowledged with a 30-day waiting The application is acknowledged with a 30-day waiting period, and allows the Board to issue a permit after 30 days period, and allows the Board to issue a permit after 60 days for a 1st class city). 30 days. The application is denied. The application is denied. Print City Name: 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 The city or county must sign before limits. (A township has no statutory authority to approve or submitting application to the deny an application, per Minn. Statutes, section 349.213.) Gambling Control Board. Print Township Name: Signature of Township Officer: Title: Date: CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) 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 t ar ithin of the event date. Chief Executive Officer's Signature: a+— Date: Signature must be CEO's signatur designee may not sign) Print Name: Bonnie Westberg JJ REQUIREMENTS MAIL APPLICATION AND ATTACHMENTS Complete a separate application for: Mail application with: all gambling conducted on two or more consecutive days, or a copy of your proof of nonprofit status, and all gambling conducted on one day.application fee (non-refundable). If the application is Only one application is required if one or more raffle drawings are postmarked or received 30 days or more before the event, conducted on the same day. the application fee is $100; otherwise the fee is $150. Financial report to be completed within 30 days after the Make check payable to State of Minnesota. gambling activity is done: To: Gambling Control Board A financial report form will be mailed with your permit. Complete 1711 West County Road B, Suite 300 South and return the financial report form to the Gambling Control Roseville, MN 55113 Board. Questions? Your organization must keep all exempt records and reports for Call the Licensing Section of the Gambling Control Board at 3-1/2 years (Minn. Statutes, section 349.166, subd. 2(f)). 651-539-1900. 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- This form will be made available in alternative format (i.e. large print, braille) upon request.