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�.G220 Ap�lica�tion fiar �xem�t ��rm�# <br />LC3CA� U���' aF G01�ER�#�AENT AC�CN�11V�.�DG�IENT <br />!f the gambling pr-�rr�ises is within c�ty �im�#s, <br />a city flfficial must chedc #he a�ion i�a# �he a#y is <br />taking on ihis applica�ion and sign the �pplica�ion. <br />The applica�on is acknowledged w�#h no wai�ing period. <br />The application �s acknowfedged w�th a 30 da� wa�ting <br />period, and a�lows the �oard to issue a permi# after 30 <br />days (60 days for a'1 s# c�ass ci#y). <br />The applica#ion �s denied. <br />Prin# c�ty narne <br />On behalf of the cit�r, 1 acknov�ledge this applica�ion. <br />Pas�E 2 0� 2 1!10 <br />if the ga�nb�ing p�-em�ses is foca#ed in a#owns�ip, a <br />coun#y of�ttya# must r�eck the action #hat #he county is taking <br />an th�s ap�ication and sign the applica#ion. <br />A township officia! is not required to sign the appiication. <br />�e applicabon 'ss acknvw�edged wi#h no waiting period. <br />= e application is acknowledged with a 30 day wai#ing <br />�eri�i, and allows �e 8oa�d to issue a permi# a#ter 30 <br />�ays. <br />� f#�e appiication is denied. <br />Prin# couniy name <br />On behal� of the coun�jr, 1 acl��owledge this applicatior�. <br />Signature flf coun#y offiaal rec�iving appfication <br />Signature o� city o�cia� receiving applica�ion <br />�_ � Ti#1e Daie I ; <br />�Optiot�$1� T01fVNSH1p: On beha�f o# #he township, i <br />Tit�e Da#e ! / ���o�d9e tfiat the organizat�on is applyir�g for exer�npted gambling <br />'—"' —"— "�""' aci�r wi#hin �ownship �imits. [A #vwnship has no s#a#u#ary authority <br />to approve or der�y an appiication jMinnesota Statu#e 349.'� fifi)] <br />Print #ownsh�p name <br />Signa#ure of township official adcnow�edg�ng appl�cation <br />Titte Date / / <br />�� <br />CH�EF EX��UT11�� �FF���R'� S�Cl�A►�'URE <br />The informaiion �vr�vided in this ap�licativn is comple�e and accurate to tt�e bes# of my kno�ledge. 1 acknowledg►e �hat the <br />financial r�port wi1� be compfeted ar�d r�ett�me�the �jErJ�i 30 days of tt�e dafe of our g►ambtir�g activity_. <br />Chief execu#ive office�'s signat�re <br />Com�lete a separat� app►ticat�on �or each g�fmbing ac�ivi#y: <br />- one day �f gambling activity, <br />- two o� rnare co�secu#ive days of gambiing activity, <br />- each day a raf�e drawing is held <br />Send appl�catifln w�ih: <br />- a copy of your p�-oof of nonprofi# status, and <br />= appfication fee for each event� <br />Make chedc payable to "State of Minnesvta." <br />To: Gambit�g Control 8oard <br />171 � West County Road �, Suite 300 South <br />Roseville, I�N 559 93 <br />Dat� ��%��/(� <br />f inancial report and recordkeeping required <br />A fnanr�al repor# ft�r�n and ins#ruc#ions wii� be sent with <br />your perrnit, or use the on�ine fi��-in form availa�ale a# <br />wwrw.gcb.state.rnn.us. Within 30 days of #he actiui#y dat�, <br />compleie and retum the f�nanciai report form to the <br />Gambling Cc�n�ro! Boar�d. <br />Que►stior�s� <br />Cali #�e Licens�r�g Section of #he Gambling Control <br />Board a# �5't -C39-4075. <br />Pri�t Forrn Reset �o�m <br />TMis foim witl i�e mada available in a!#emative <br />format (i.e. large print, 8railie) u�on reques�. <br />Data prnracy no#ice:T�e ir�formation requested <br />on this foRn (and ar�y at#achmen#s) wi�l be t�s� <br />by the Gambling �ontro! goard (Board) to <br />determine your organiia#ivn's qualificatio►�s to <br />be invofired in lawfui gambling ac�ties in <br />Minnesota. Y�ur organiza�ior� has #he right to <br />refuse to suppiy #he i�forrna#ior� �equested; <br />however, i# your organiza�on retuses ia supp�y <br />#his informafior�, the 8oard �nay not be a1�e #o <br />deter�nine your organization's qualifications <br />and, as a cx�sequenoe, �ay refuse #o iss� a <br />permi#. if you suppfy �he i�t�ormation �que�ted, <br />the 8oard will be able to �rocess your <br />o�gar�iz.ation's appiicatior�_ Yaur or�ganiza#�on's <br />na�e and address wil� be pubiic informafi�r� <br />when �ceived by the Boa�rd. Ai! other <br />ir�o�rnation provided wi�! be private data unfil <br />the �oard issues #he pern�;t Vlfien the 8oard <br />issues the permit, ati info�rnation provided wil! <br />bec�� publ�c. !� tfie Board does not issue a <br />pe�m�#, aii informa�on p�ovided �emai�s priva#e, <br />wi#h #he excep�ion of your arganiza#ion's name <br />and add�ess whic� wi�i �ernain public. Private <br />d�ta are availabie to: 8oar�d members, Board <br />s#aff whose work �equires aG:ess to the <br />infamatir3n; Minnesota's Departrr�ent o# <br />P�btic Safety; Attomey General; <br />C�missio�ers af Adr��nistration, Minnesota <br />Management & 8udget, and Revenue; <br />Legistative At�di#or, na#ional and i�tema#ionai <br />gan�biing regulatory age�aes; ar�yone pursuant <br />�o court order; other indiv�dua�s ar�d agencies <br />specific�tly a{�ihoriaed by state or #edera! law to <br />t�ave access #o #he infionna#ion; individuals and <br />agenaes for whic�a 1aw or legal order authorizes <br />a new use or sharing of informafion after #his <br />�Votioe was given; and anyone wi#h your written <br />t:onsent <br />