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LG220 Application for Exempt Permit Page 2 of 2
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<br /> L LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to
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<br /> Mill
<br /> the Minnesota Gambling Control Board)
<br /> CITY APPROVAL COUNTY APPROVAL
<br /> for a gambling premises for a gambling premises
<br /> located within city limits located me township
<br /> The application is acknowledged with no waiting period, he application is acknowledged with no waiting period,
<br /> The application is acknowledged villith a 30-day wafting he application is acknowledged with a 30-day waiting
<br /> period, and allows the Board to issue per after 30 days period, and allows the Board to issue as perruit after
<br /> (60 days for a t class city), 30 days,
<br /> E]The application is denied, he application is denied,
<br /> Print City Print County Name,
<br /> Signature ofCfty Pere nnel: Signature of County Personnel:
<br /> ................................
<br /> Thle4 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 /> The city or county must sign before limits. (A township has no statutory authority to approve or
<br /> submitting application to the deny an application, per when, Statutes, section 349.213,),
<br /> Gambling Control Board. ...............
<br /> Signature of Township Officer:
<br /> Title: Datvx ______________________________
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<br /> CHIEF EXECUTIVE OFFICER'S SIGNATURE (required)
<br /> ._.._.._.....w.....................................
<br /> This infigirtnatiOn provided In this application is completeray.d the best of my knowledge. I acknorioledge that the financial
<br /> report will be completed and returned to' he in days tfte eased r date,
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<br /> I Chief Executive officer's Signature, Data, —Pr
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<br /> (signs li-ke ust b a al ature; as may notTicin)
<br /> 1 Print Name, _!tich Berg ....
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<br /> REQUIREMENTS 1HAILAPPLICATION AND ATTACHMENTS
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<br /> Complete a separate application for: Mail application with:
<br /> • all gambling conducted on two or or more consecutive days, or ................a copy of your proof of nonprofit status; and
<br /> • all gambling conducted on one day,
<br /> application fee(non-refundable). if the application is
<br /> Only one application is required if one or mors raffle drawings are postmarked or received 30 days or,for before the ovent,
<br /> conducted on the same day. the application Fee is$100; otherwise the fee is$150,
<br /> Financial report to be completed within 30 days after the Make check payable to State of Minnesota.
<br /> I gambling activity Is done, Tara Minnesota Gambling Control Board
<br /> I A financial report form will be mailed with your permit. Complete 1711. West County Road B,Suite 300 South
<br /> and return the financial report form to the Gambling Control Roseville, MN 55113
<br /> Board.
<br /> Questions?
<br /> Your organization must keep all exempt records and reports for
<br /> Call the Licensing Section of the Garnbhng Control Board at
<br /> 3-1/2 Boom (Minn, Statutes, section 349,166,suled, 2(f)), 651-539-1900,
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<br /> Data privacyfo
<br /> notice he inrmation r 'existed appmgraam
<br /> lication. Your antion's nam avail enc of public Safety;Adol-ne.y General;
<br /> off this form and any attachments)win be used address will be public WiformatiOn when recahoad commissioners of Administration,Minnesota
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<br /> by the Gambillng Cantrall Board(Board)to by the nes, Aro
<br /> wli other information pvided will Management&Budget and Revenueaffislative
<br /> del: Zia long to
<br /> L lantrilne Your orgam tions cloafificat: be private data about your organization until the Auditor, national and international gambling
<br /> be involved fn lawful gambling activities in Board issues the permit, other the Board hisrurv; regulatory agencies;anyone pursuant to court
<br /> Minnesota, Your,organization has the fight to the pernift,all information provided will becorne order;other individuals and agencies specifically
<br /> at se to supply the,information; malsever, if public, If the Board does not issue a permit,all authorized by State to federal law to have access
<br /> your moarnzation refuses to supply this information provided riernaMr private,wini the to the information; individuals and agencies for
<br /> information,the Board may not be able to exception of your ear gairliZation'a name and which law or legal order outdarizew a new use or
<br /> determine your organizatlons qualifications and, address which will remain public, Private data sharinn of inforrivition utter tals notice were
<br /> as a consequence, may retrace to issue a permit, about your organization are available to Board given;and anyone with your written consent,
<br /> If your organization supplies the information mernbers,Board staff whose work mairares
<br /> requested,the Board will be able to process me access to the inforroatior, Minnessim's Depart.
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<br /> This form will,)a made available to alternative forrriat(i,elarge print, braille)upon request,
<br /> Ail art sat olawrowuh;arripliever
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