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