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LG220 Application for Exempt Permit 3/14 Page 2 of 2 <br /> LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT <br /> CITY APPROVAL COUNTY APPROVAL <br /> for a gambling premises for a gambling premises <br /> located within city limits located in a township <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 days period, and allows the Board to issue a permit after 30 <br /> [60 days for a 1st class city]. days. <br /> The application is denied. The application is denied. <br /> Print city name Print county name <br /> Signature of city personnel Signature of county personnel <br /> Title Date Title Date <br /> TOWNSHIP.If required by the county. <br /> On behalf of the township, I acknowledge that the organization <br /> is applying for exempted gambling activity within the township <br /> limits. <br /> [A township has no statutory authority to approve or deny <br /> an application, per Minnesota Statutes 349.166.] <br /> Print township name <br /> Signature of township officer <br /> Title 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 financial <br /> report will be completed and returned y1the rd within 30 days of the event date. /L <br /> Chief executive officer's signatureDate '7 <br /> Print name Greg Kieselhorst <br /> REQUIREMENTS <br /> Complete a separate application for. Rnandal report and recor+dkeepirg required <br /> • all gambling conducted on two or more consecutive days,or A financial report form and instructions will be sent with your <br /> • all gambling conducted on one day. permit,or use the online fill-in form available at <br /> Only one application Is required if one or more raffle drawings www.gcb.state.mn.us. <br /> are conducted on the same day Ili Within 30 days of the event date,complete and return <br /> Send application with: the financial report torn to the Gambling Control Board. <br /> _a copy of your proof of nonprofit status,and Questions? <br /> _application fee(non refundable). Make check payable to Call the licensing Section of the Gambling Control Board <br /> "State of Minnesota." at 651-539-1900. <br /> To: Gambling Control Board This form will be"rade available in alternative format(i.e.large print,Braille) <br /> 1711 West County Road B,Suite 300 South upon request <br /> Roseville,MN 55113 <br /> Data privacy notice: The Information requested on this AN other Information provided will be pri- General;Commissioners of Administration, <br /> form(and any attachments)will be used by the Gambling vate data about your organization until the Minnesota Management&Budget,and <br /> Control Board(Board)to determine your organization's Board Issues the permit. When the Board Revenue;Legislative Auditor,national and <br /> qualifications to be involved in lawful gambling activities in Issues the permit,all Information provided international gambling regulatory agencies; <br /> Minnesota. Your organization has the right to refuse to will become public. If the Board does not anyone pursuant to court order;other indi- <br /> supply the Information; however,If your organization Issue a permit,all Information provided viduals and agencies specifically authorized <br /> 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 <br /> able to determine your organization's qualifications and, organization's name and address which will the information;individuals and agencies <br /> 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 <br /> organization supplies the Information requested,the Board organization are available to: Board mem- new use or sharing of information after this <br /> will be able to process the application. Your organization's bers,Board staff whose work requires notice was given;and anyone with your <br /> name and address will be public Information when received access to the Information;Minnesota's written consent. <br /> by the Board. Department of Public Safety;Attorney <br />