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LG22O Application for Exempt Permit LUtt Page 2 of 2 LOGAL UilrT OF GOVERilfEilT ACKIIOWLEDGIIENT (rcqulrcd beforc submltting.ppllc.tion b thc ilanncaota Gambltng Control Board) CITY APPROVAL for a gambling premises located within city limits The application is acknowledged with no waiting period. The application is acknowledged with a 30-day waiting period, and allows the Board to issue a permit after 30 days (60 days for a lst class city). The app lication is denied .lh'dPrint City Name: Signature of City Personnel Title Date The city or county must sign before submitting application to the Gambling Control Board. COUNTY APPR,OVAL for a gambling premises located in a township application is acknowledged with no waiting period application is acknowledged with a 30-day waiting period, and allows the Board to issue a permit after 30 days. application is denied. Print County Name: Signature of County Personnel: 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 deny an application, per Minn. Statutes, section 349.213.) Print Township Name: Signature of Township Officer: Title:Date CHIEF EXECUTM OFEICER'S SIGNATURE (required) The information provided in this ap is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned Board 30 of the event date. Chief Executive Officer's Signature :Date '.-D^- 77,2"? I Signature must be CEO's sig re; designee may not sign) Print Name: REQUIREMENTS MAIL APPLICATION AND ATTACHMENTS Complete a separate application for:. all gambling conducted on two or more consecutive days; or. all gambling conducted on one day. Only one application is required if one or more raffie drawings are conducted on the same day. Financial repoft to be completed within 3O days after the gambling actlvity is done: A financial report form will be mailed with your permit. Complete and return the financial report form to the Gambling Control Board. Your organization must keep all exempt records and reports for 3-L/2 years (Minn. Statutes, section 349.166, subd. 2(f)). t{ail application with: a copy of your proof of nonprofit status; and application fee (non-refundable). If the application is postmarked or received 30 days or more before the event, the application fee is llOO; otherwise the fee is 115O. Make check payable to State of lrlinnesota. To: Minnesota Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Questions? Call the Licensing Section of the Gambling Control Board at 651-539-1900. Data privacy notice: The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your organization's qualifications to be involved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the information; however, if your organization refuses to supply this information, the Board may not be able to determine your organization's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the information requested, the Board will be able to process the application. Your organization's name and address will be public information when received by the Board. All other information provided will be private data about your organization until the Board issues the permit. When the Board issues the permit, all information provided will become public. If the Board does not issue a permit, all information provided remains private, wlth the exception of your organization's name and address which will remain public. Private data about your organization are available to Board membe6, Board staff whose work requires access to the information; Minnesota's Depart- ment of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent. This form will be made available in alternative format (i.e. large print, braille) upon request. An egual opportunlty emdoyer