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LG220 Application for Exempt Permit 4/23 Page 2 of 3 LOCAL UNTI" OF GOVERNMENT ACKNOWLEDGMENT (required before submitting application to the Minnesota Gambling Control Board) CITY APPROVAL for a gambling premises located within city limits ®The application is acknowledged with no wafting period, FIT'he application is acknowledged with a 30-day waiting poriod, and allows the hoard to issue a permit after 30 days (bQ days for a 1st class city),. ❑The application is denied Print City Name: Signature of City Personnel: Title Date: The city or county must sign before submitting application to the Gambling Control Board. COUNTY APPROVAL for a gambling premises located in a township 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. F-1The application is denied. Print County Name: Signature of County Personnel: Title: ❑ate: 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 an application, per Minn. Statutes, section 349.213.) Print Township Name: Signature of Township Officer: Title: Date: CHIEF EXECUTIVE OFFICER'S SIGNATURE (required) f The information provided In this application is complete report will be completed and returned tethe Board Witt Chiet Executive Officer's Signatu S16n*wA0fnus: be Print Name: Ron Hogan REQUIREMENTS AaCxate to the best of my knowledge. I acknowledge that the financial days of the event date. Date: signature; designee m of sign) Complete a separate application for: • all gambling conducted on two or mart; consecutive days; or • all gambling conducted on one day. Only one application is required if one or more raffle drawings are conducted on the same day. Financial report to be completed within 30 days after the gambling activity Is done: A financial report form will be mailed with your permit. Complete and return the financial report form to the Gambling Control Board. Your organization must keep all exempt records and reports for 3-1/2 years (Minn. Statutes, section 349.166, subd. 2(f)). MAIL APPLICATION AND ATTACHMENTS Mall application with: a copy of your proof or nonprofit status; and application fee (non-refundable). If the application is postmarked or received 30 days or more before the event, the application fee is $100; otherwise the fee is $130. Make check payable to State of Minnesota. To: Minnesota Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Questions? Call the Licensing Section of the Gambling Control Board at 651-539-1900 Data privacy notice: The information requested application. Your organimtlon`s name and ment of Public Safety; Attorney General; on this form (and any attachments) will be used address will be public information when received CommNsIoners of Administration, Minnesota by the Gambling Control Board (Board) to by the BaaM. Ail other information provided will Management a Budget, and Revenue; Legislative determine your arganization's qualifications to be private data about your organization until the Auditor, national and inlernatlonal gambling be involved in lawful gambling activities in Board issues the pennit. When the Board issues regulatory agencies; anyone pursuant to court Minnesota. Your organization has the right to the permit, all info-mation provided will become order; other individuals and agencies specifically refuse to supply the Information; however, if public. If the Board does not Issue a permit, all authorized by state or federal law to have access your organization refuses :n Ripply this Information provided reirwins private, with the to the information; individuals and agencies for Information, the Board may not be able to exception of your nrganization's name and which law ❑- legal order authorizes a new use or determine your organizations qualifications and, address which will remain public. Private data sharing of information after this notice was as a consequence, may refuse to issue a permit, about your organivation are available to Board given; and anyone with your :%mitten consent. If your organizatlon s:ippRrrs the information members, Board steff whose work requires requested, the Board wlli be able to process the access to the information; Mnneso.a's Depart - This form will be made available in al.ernat"ve format (i.e. large print, braille) upon request.. An equal oppw4unlry employer