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. . . Application for Exempt Permit -lG220 Page 2 8~~~ Organization NameM"1L~~.fuci ~-0f.J~~------------------------ Local Unit of Government ACknowledgm~--;:;t0 If the gambling premises Is within city limits, the city must sign this application. On behalf of the city, I acknowledge this application. Check the action that the city is taking on this application. fVI The city approves the application wtth no I,c.I watting period. O The city approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city). o The city denies the application. (Signature of city personnel rec iving application) Tnle__idJi _:(~~~^!".~ _________ Datef:>~__f_~~__d~1_ If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county is taking on this application. o The county approves the application with no waiting period. o The county approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days. o The county denies the application. Print name of county ____________________________ (Signature of county personnel receiving application) T~le _________________________________ Date_____f____f____ TOWNSHIP, On beha~ of the township, I acknowledge that the organization is applying for exempted gambling activity w~hin the township limits. [A township has no statutory authority to approve or deny an application (Minn, Stat. sec. 349.213, subd. 2).] Print name of township _____________________________ (Signature of township official acknowledging application) T~le________________________ Date__I___C__ Chief Executive Officer's Signature./.' The information provided in this applicaY9l1 is / Chief executive officers signatureL'..__~/. / Name (please A~o..("~ ]) 6 iii bp>/~:,.fL T Date ~/ 151 .:::>/ Mail Application and Attachments At least 45 days prior to your scheduled activity date send: the completed application, a copy of your proof of nonprofit status, and . a $25 application fee (make check payable to "State of Minnesota"). Application fees are not prorated, refundable, or transferable. Send to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 If your application has not been acknowledged by the local untt of government or has been denied, do not send the application to the Gambling Control Board.