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<br />LG220 Application for Exempt Permit <br /> <br />Organization Name ?(;\.-...Jlwi;l\!I~ 1.--l0\-l7 <br /> <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises is within city limits, the <br />city must sign this application. <br /> <br />On behalf of the city, I acknowledge this application. <br /> <br />Check the action that <br />the city is taking on this application. <br /> <br />O The city approves the application with no <br />waiting period. <br /> <br />O The city approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city) . <br /> <br />o The city denies the application. <br /> <br />Print name of city <br /> <br />Signature of city personnel receiving application <br /> <br />Title <br /> <br />Oate----1----1_ <br /> <br />Page 2 of 2 <br />2/06 <br /> <br />?-L..vi;' <br /> <br />If the gambling premises is located in a township, both <br />the county and township must sign this application. <br /> <br />On behalf of the county, I acknowledge this application. <br /> <br />Check the action that <br />the county is taking on this application. <br /> <br />o The county approves the application with no <br />waiting period. <br /> <br />o The county approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days. <br /> <br />o The county denies the application. <br /> <br />Print name of county <br /> <br />Signature of county personnel receiving application <br />Title <br />Oate-.--l-.--l_ <br /> <br />TOWNSHIP: On behalf of the township, I acknowledge that <br />the organization is applying for exempted gambling activity <br />within the township limits. [A township has no statutory <br />authority to approve or deny an application <br />(Minnesota Statute 349.213, subd. 2).J <br /> <br />Print name of township <br /> <br />Signature oftownship official acknowledging application <br />Title <br />Oate_I-.-I_ <br /> <br />Chief Executive Officer's Signature <br /> <br />The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that <br />the financial report will be completed and returned to the Gambling ntrol Board within 30 days of the date of our <br />gambling activity. <br /> <br /> <br />Chief executive officer's s. <br /> <br />Name (please print) <br /> <br />Mail Application and Attachments <br /> <br />Date C / .,;l.;r / ~ <br /> <br />Complete an application for each <br />gambing activity: <br />. one day of gambling activity <br />. two or more consecutive days of <br />gambling activity <br />. each day a raffle drawing is held <br /> <br />Send <br />. the completed application, <br />. a copy of your proof of nonprofit status, and <br />. a $50 application fee. Make check payable to "State of Minnesota"). <br /> <br />To: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br /> <br />Jj1 <br />