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LG220 Application for Exempt Permit Page 2 of 2 ���o <br /> LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT <br /> If the gambling premises is within city limits, If the gambling premises is located in a township, a <br /> a city official must check the action that the city is county official must check the action that the county is taking <br /> taking on this application and sign the application. on this application and sign the application. <br /> A township official is not required to sign the application. <br /> ' The application is acknowledged with no waiting period. The application is acknowledged with no waiting period. <br /> The application is acknowledged with a 30 day waiting The application is acknowledged with a 30 day waiting <br /> period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 <br /> days (60 days for a 1st class city). days. <br /> �The application is denied. The apptication is denied. <br /> Print county name <br /> Print city name On behalf of the county, l acknowledge this application, <br /> On behalf of the cify, / acknowledge this application. Signature of county official receiving application <br /> Signature of city official receiving application <br /> TiUe Date / / <br /> (Optionalj TOWNSHIP: On behalf of the township, I <br /> Title Date / / acknowledge that the organization is applying for exempted gambling <br /> activity within township limits. [A township has no statutory authority <br /> to approve or deny an apptication [Minnesota Statute 349.166)] <br /> Print township name <br /> Signature of township official acknowledging application <br /> Ti�e Date / / <br /> CHIEF EXECUTIVE OFFICER'S SIGNATURE <br /> The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the <br /> financial report will be completed and retum #o the Boa wit in 0 days of the date of our gamblirrg activity. <br /> Chief executive officer's signature � Date ,k.�; l��' A 4l ( <br /> Complete a separate application for each gambing activity: anciat report and recordkeeping required <br /> - one day of gambling activity, A financial report form and instructions will be sent with <br /> - two or more consecutive days of gambling activity, your permit, or use the online fill-in form available at <br /> - each day a raifle drawing is held www.gcb.state.mn.us. Wrthin 30 days of the activity date, <br /> Send application with: complete and retum the financial report form to the <br /> - a copy of your proof of nonprofit status, and Gambling ConVol Board. <br /> - application fee for each event. <br /> Make check payable to "State of Minnesota " <br /> To: Gambling Control Board <br /> 1711 West County Road B, Suite 300 South <br /> Roseviile, MN 55113 Print Form Reset Form <br /> the Board wrill be able to process your information; Minnesota's De <br /> This form will be made available in altemative partment of <br /> ' format (i.e. large prinf, Braille} upon request °r9anization's application. Your organiza6on's public Safety; Attomey General; <br /> Data privacy notice:The information requested <br /> name and address unli be public information Commissioners of Administration, Minnesota <br /> when received by the Board. All other Mana ement & Bud <br /> on this form (and any attachments) will be used ��ormation provided will be private data until 9 get, and Revenue; <br /> by the Gambling Control Board (Board) to Legislative Auditor, �ational and intemational <br /> determine your organization's qualifications to �e Board issues the permit. When the Boarc! ��bfing regutatory agencies; anyone pursuant <br /> issues the pem+it, all information provided will to court order; other individuals and a encies <br /> be involved in lawful gambling aetivities in g <br /> Minnesota. Your organization has the right to become public. If the Board does not issue a speafically authorized by state or federal law to <br /> refuse to supply the ir�formation requested; Permit, all information provided remains private, have access to the information; individuals and <br /> however, 'rf your organization refuses to supply W�� �e excepHon of your organization's name agencies for which law � legal order authorizes <br /> and address which will remain public. Private <br /> this information, the Board may not be able to a new use or sharing of information after this <br /> detertnine your organization's qualifications data are available to: Board members, BoarcJ Notice was given; and anyone with your written <br /> staTf wh work i s a <br /> and, as a consequence, may refuse to issue a ose requ re ccess to the �sent. <br /> permit If you supply the information requested, , <br /> $ <br />