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05-08-23-R
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05-08-23-R
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LG220 Application for Exempt Permit <br />4/22 <br />Page 2 of 4 <br />LOCAL UNITWE GO RNMENT ACKNO EDGMENT (required before submitting application to <br />the Minnesota Gambling Control Board) <br />CITY APPROVAL <br />for a gambling premises <br />located within city limits <br />The application is acknowledged with no waiting period. <br />❑The application is acknowledged with a 30-day waiting <br />period, and allows the Board to issue a permit after 30 days <br />(60 days for a 1st class city). <br />❑The application is denied. <br />Print City Name: <br />Signature of City Personnel: <br />Title: Date: <br />The city or county must sign before <br />submitting application to the <br />Gambling Control Board. <br />COUNTY APPROVAL <br />for a gambling premises <br />located in a township <br />The application is acknowledged with no waiting period. <br />The application is acknowledged with a 30-day waiting <br />period, and allows the Board to issue a permit after <br />30 days. <br />The application is denied. <br />,_ I Print County Name: <br />Signature of County Personnel: <br />Title: <br />_____ Date: <br />TOWNSHIP (if required by the county) <br />On behalf of the township, I acknowledge that the organization <br />is applying for exempted gambling activity within the township <br />limits. (A township has no statutory authority to approve or <br />deny an application, per Minn. Statutes, section 349.213.) <br />Print Township Name: <br />Signature of Township Officer: <br />Title: <br />CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) <br />Date: <br />The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial <br />report will be completed and returnedZhe Boar ni in 30 days of the event date. <br />Chief Executive Officer's Signature; � "\ )_ _ Date: 1 6LI 12,3 <br />(Signature must be CEO's signature; designee may not sign) <br />Print Name: Peter Belsito <br />REQUIREMENTS N IMAILAPPLICATIO AND ATTACHMENTS <br />Complete a separate application for: Mail application with: <br />• all gambling conducted on two or more consecutive days; or _ a copy of your proof of nonprofit status; and <br />• all gambling conducted on one day. <br />__ application fee (non-refundable). If the application is <br />Only one application is required if one or more raffle drawings are postmarked or received 30 days or more before the event, <br />conducted on the same day. the application fee is $100; otherwise the fee is $150. <br />Financial report to be completed within 30 days after the Make check payable to State of Minnesota. <br />gambling activity is done: To: Minnesota Gambling Control Board <br />A financial report form will be mailed with your permit. Complete 1711 West County Road B, Suite 300 South <br />and return the financial report form to the Gambling Control Roseville, MN 55113 <br />Board. <br />Questions? <br />Your organization must keep all exempt records and reports for Call the Licensing Section of the Gambling Control Board at <br />3-1/2 years (Minn. Statutes, section 349.166, subd. 2(f)). 651-539-1900. <br />Data privacy notice: The information requested application. Your organization's name and ment of Public Safety; Attorney General; <br />on this form (and any attachments) will be used address will be public information when received Commissioners of Administration, Minnesota <br />by the Gambling Control Board (Board) to by the Board. All other information provided will Management & Budget, and Revenue; Legislative <br />determine your organization's qualifications to be private data about your organization until the Auditor, national and international gambling <br />be involved in lawful gambling activities in Board issues the permit. When the Board issues regulatory agencies; anyone pursuant to court <br />Minnesota. Your organization has the right to the permit, all information provided will become order; other individuals and agencies specifically <br />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 <br />your organization refuses to supply this information provided remains private, with the to the information; individuals and agencies for <br />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 <br />determine your organization's qualifications and, address which will remain public. Private data sharing of information after this notice was <br />as a consequence, may refuse to issue a permit. about your organization are available to Board given; and anyone with your written consent. <br />If your organization supplies the information members, Board staff whose work requires <br />requested, the Board will be able to process the access to the information; Minnesota's Depart - <br />This form will be made available in alternative format (i.e. large print, braille) upon request. <br />An equal opportunity employer <br />
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