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LG220 Application for Exempt Permit 12/12 Page 2 of 2 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township 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 days period, and allows the Board to issue a permit after 30 [60 days for a 1st class city]. days. The application is denied. The application is denied. Print city name Print county name Signature of city personnel Signature of county personnel Title Date Title Date TOWNSHIP. If required by the county. On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. [A township has no statutory authority to approve or deny ` p tllllIilllj an application, per Minnesota Statutes 349.166.] Print township name Signature of township officer Title Date CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this applic tion is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned th Board within 30 d ys of the event date. Chief executive officer's signature Date Print name -1 - 0 k-k "3 REQUIREMENTS Complete a separate application for: Financial report and recordkeeping required • all gambling conducted on two or more consecutive days, or A financial report form and instructions will be sent with your • all gambling conducted on one day. permit, or use the online fill -in form available at Only one application is required if one or more raffle drawings www•gcb.state.mn.us. are conducted on the same day Within 30 days of the event date, complete and return Send application with: the financial report form to the Gambling Control Board. _ a copy of your proof of nonprofit status, and Questions? _ application fee (non refundable). Make check payable to Call the Licensing Section of the Gambling Control Board "State of Minnesota." at 651- 639 -4000. To: Gambling Control Board This form will be made available in alternative format (i.e. large print, Braille) 1711 West County Road B, Suite 300 South upon request. Roseville, MN 55113 Data privacy notice: The information requested on this All other information provided will be pri- General; Commissioners of Administration, form (and any attachments) will be used by the Gambling vate data about your organization until the Minnesota Management & Budget, and Control Board (Board) to determine your organization's Board issues the permit. When the Board Revenue; Legislative Auditor, national and qualifications to be involved in lawful gambling activities in Issues the permit, all information provided international gambling regulatory agencies; Minnesota. Your organization has the right to refuse to will become public. If the Board does not anyone pursuant to court order; other indi- supply the information; however, if your organization issue a permit, all information provided viduals and agencies specifically authorized refuses to supply this information, the Board may not be remains private, with the exception of your by state or federal law to have access to able to determine your organization's qualifications and, organization's name and address which will the information; individuals and agencies as a consequence, may refuse to issue a permit. If your remain public. Private data about your for which law or legal order authorizes a organization supplies the information requested, the Board organization are available to: Board mem- new use or sharing of information after this will be able to process the application. Your organization's bers, Board staff whose work requires notice was given; and anyone with your name and address will be public information when received access to the information; Minnesota's written consent. by the Board. Department of Public Safety; Attorney 32