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C *g 1 20 03 : 1 7p Bon i Westberg <br />Lc22O Application for Exernpt permit <br />651-429-?534 p.3 <br />tvLT <br />Page 2 of 2LOCALuilrTOFGOYERTIHENTACKNOWTEDG}IE]IIT (reguired subefoletheH bmitting fcationinnesotaapPl toGambliControlngEoard) <br />qITY APPROVAL <br />tor a gnmbling premlses <br />loceted withi; Cty tirnits <br />applicatbn is acknowledg€d wiB, no waiting period, <br />The city or county must sign before <br />submitting applicafion to the <br />Gambting Controt Board. <br />Signature of City personnel: <br />Tffl <br />Print City MN <br />Date <br />a 30-day waiting <br />a permit after 30 days <br />Name: Arden <br />The applicaUon is denied. <br />appllcation is acknowtedged wfth no waiting perlod. <br />Igyf:tl?.(if requir.gd bv the Gounty)on beharf of the township, I acknowreog; in"t the organizationls a p pryin g tor exernpted- ia m br in g J cti rity wttrrrn-the-town sh ipl,lmits. (A townshp rras n6 st"hrh;; auth;fty 6 #i"ir" ol,deny an appficason. per Mrnn. stot to, sectibn s+6liig,l <br />Date: <br />DateTitle <br />ledged <br />Board to30 <br />applkation is ackrnw -with a 30-day waiting <br />issue a prmit afterperiod, and allows the <br />Signature of County personnd: <br />Print County Narne: <br />Print Township Name: <br />Signature of Township Officer: <br />Tifle: <br />COUNTY APPROYAL <br />fgr a gnrnbllng premises <br />located in a towrrshtp <br />days. <br />apptlcation is denied. <br />FCHIE EXECUTIVE o F EICER'S SIGH'TTURE (reguirEd ) <br />Chief Executive Offlcer's Slgnature: <br />rnust be CECI's signature; <br />Print Narne:Boni <br />Date:/n <br />b the best of my <br />ttre event date. <br />o <br />The information provUed in this applicatlon is complete and accuratereport will be completed and returned to knowledge.I acknowledge that the financial <br />may not sBn) <br />REQUTRCI{ErTs APPLICATIO ATTlrlAlLilATTD ACH}I E r$Ts <br />only one application is requlred if one or mor€ raffre drawing$ areconducted on the same day. <br />Fln.nsst report t1 bG comproted r,niurin 30 dayr after thegamDling lctivltV is donc: <br />A frnancial report form rviil be rnaihd with your perrnit. compreteand retum the financiat report fiorm to tt " c"-[ri"g'Ein*rBoard- <br />Your^organizaUon m_ust keep all exenrpt records and3-Ll2 years (tr{inn. Statutes, secilon g+g.fgO,-srfi;.reports for <br />2(O), <br />ys; <br />Co aCmplet t eparate foapplication r!all blmga condiru onucted otllro rnor re consecuti ve da oraallamgeonductednbllngoonetlay a copy of your prroof of nonprofit status; and <br />applica$on fee (non-refundable). If the appthation ispostmarked or recdved 30 days or more 6irore the event, <br />[te- appllcaUon fe-e is flOO; oth_envise tfr. ie* [ *fSO.i.take check payable to s.irh or minn*d]- " <br />To: Minnesota Gambling Contrql Boanl1711 West County noaa h Suite 300 SouthRosevllle, MN SStl3 <br />Questlons? <br />9l ll1e_Licglging Secuon of Ure Gambting Control Boarct at65r-539-19fi). <br />iiail apptication with: <br />Oate prlvacy noue: The lnformaHon rtguested *pllcati on. Your organizationt name andon th is fonn (and any attactmentsl r*ill De used address will be pubffc informailon when recelvedbythe Garnbling Control Board (Eoard) to by ttrc Board. All other lnhrmatbn provtded rllldrtermine yo.lr organizationt guallflcaUons to be priuate tlata about your organization unUl thebe involved in lasrful gambtfn g activities ln Board lssues the permlt. When the goard issuesl'lhnesota.Your organiza$on has the right to the permit,all irformation provided wiil becomerefuse to supply the information ; however, If public. If the Board do€s not issue a perrnit, altyour organiEation refuses to sup plv thts informatio n pmvided rernains prlvate, wiEr theintonnation, the Board may not be able to excepEon of your organizationt nama anddetermlne your organ izationt quattfications an 6,address whirf,r will rernain publlc. priyate datEas a cDns equenoE, may retlse to lssre a p€rm lt. about your lzatlon are avallable to BoatdIf your or9 anization supplies <br />the Boeru, wil! be <br />the lnformatbn members, Board staff whose yrork rcqulres <br />or9rn <br />requested,aUe to process the <br />An qtle,l oppoftunity Gmgtoyct <br />aEc€ss to the information;llinnesota's Depaft- <br />Thls form w ilt be mad E available in alternatirre format .G(i large DrlnL uPonbraille)request.