2011-12-14 CC Packet - Laserfiche WebLink

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LG220 Application for Exempt Permit It the gambling premises is located in a township, a county official must check the action that the county is taking on this application and sign the application. A township official is not required to sign the application. OF If the gambling premises is within city limits, a city official must check the action that the city is taking on this application and sign the application. _The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a tat Gass city). _The application is denied. Print city name On behalf of the city, I acknowledge this application. Signature of city official receiving application _The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day wafting period, and allows the Board W issue a permit after 30 days. _The application is denied. Print county name On behalf of the county, t acknowledge this application. Signature of county official receiving application Page 2 of 2 1111 (Optional) TOWNSHIP: On behalf of the township, I Title Dale I I acknowledge that the organization is applying for exempted gambling activity within township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349.166)] Print township name Signature of township official acknowledging application I CHIEF EXECUTIVE OFFICER'S SIGNATURE I 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 returned to the Board within 30 days of the date of our gambling activity. Chief executive officer's Complete a separate application for each gambing activity: - one day of gambling activity, -two or more consecutive days of gambling activity, - each day a raffle drawing is held Send application with: - a copy of your proof of nonprofit status, and - application fee for each event. Make check payable to "State of Minnesota.' To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Date Financial report and recordkeeping required A financial report form and instructions will be sent with your permit, or use the online fill -In form available at www.gcb.state.mn.us. Within 30 days of the activity date, complete and return the financial report form to the Gambling Control Board. PrIM Farm Reset form This form will be made available in allemative format (i.e. large print, Braille) upon request. Data privacy notice:The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine, your organization's qualifications to be involved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the information requested; however, If your organization refuses to supply this information, the Board may not be able to determim your organization's qualifications and, as a consequence, may refuse to Issue a permit. If you supply the information requested, the Board will be able to process your organization's application. Your organization's name and address will be public information when received by the Board. All other information provided will be private data until the Board issues the permit. When the Board issues the permit, all information provided will become public. If the Board does not issue a permit, all information provided remains private. with the exception of your organization's name and address which will remain public. 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, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies 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 written consent. 30