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TttJe (~I_~_I_i"".llf.I.~ll_I.llt'" ThtJ information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report wiN be completed a;:;~me:, to :;~ar; within ~ ,!~ of ~e;;:;: our gambling activity. Chief executive officer's signatl:i!..... -.....~,...~ , Date If the gambling premises is within city limits, a city oflel.1 must check (X) the acleA that the cltr I. taking en ..is application and s-lgR the a.pptlcatien. _Tne applicatien is acknowledged with no wa;it~ng period. _The application is aeknowledgea"with a 30 Gay waitiAg period, and affowsthe Board to issue a permit after 30 days (60 days for a 1;8t €lass city). _The application is Elenied. Print city name On behalf 0f the city, I acknowledge this application. Signature of city official receiving application Title Date_,_,_ Complete a separate application for each gambing activity: - one day ot gambling activity, - two or more consecutive days af gambling activity, - each day a raffle drawing is held Send appflCation with: a copy af your proof of nonprofit status, and $50 app/Ication fee for each event Make check payable to "State of Minnesota. II To: Gambling Control Board 1711 West County Road 8, Suite 300 South R05eville, UN 55113 Page 2 ef 2 9/08 If the gambling premises is located in a township, a county Qffielal must check (X) 1be actien that the county Is taking eft tbfs ..pplica.tion .:Ad .ign the application. A towns-hip official must also S:'tn ... application. _The application is acknowfedged with no waiting J)eriod. _The application is acknowledged with a 30 day waitinSj period, and aUows the Beard to issue a permit after 30 ~ays. _The aJ')plication is denied. Print OOUAty name On behalf of the eounty, lacknowledg6 this application. Signature of county official receiving application Title Date-.l-.l_ TOWNSHIP: On behalf of the township, I acknowledge that the OfSJanlzation is applying for exempted gambliAg activity within township limits. fA township has no statutory authority to approve 6f deny an application (Minnesota Statute 349.213, subd. 2)) Print township name Signature af township official acknowled9ing application Date-.l_'_ Financial report and recordkeeping required A linancia.J report fonn and inStructions will be sent with your permit. Within 30 days of the act1YJty date, complete and return the financial report form to the Gambling Control8oarcJ. Questions? Can the licensing Sectjon of the Gambling Control Board at 651-639-4076. Data privacy. This form will be made available the Board will be able to process your in alternative format (i.e. large print, Braille) application. Your name and and your upon request. The information requested on organization's name and address will be public this form (and any attachments) will be used by infonnation when received by the Board. All the Gambling Control Board (Board) to the other infonnation you provide wHI be private determine your qualifications to be involved in data until the Board issues your permit. When lawful gambling activities in Minnesota. You the Board issues your permit, aU of the have the right to refuse to supply the information provided to the Board will become information requested; however, jf you refuse to public. If the Board does not issue a permit, all supply this information, the Board may not be information provided remains private, with the able to determine your qualifications and~ as a exception of your name and your organization's consequence, may refuse to issue you a permit. name and address which will remain public. If you supply the information requested, Private data are available to: Board members, Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order. other individuals and agencies that are 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 consent.