2006-12-27 CC - Set Agenda - Laserfiche WebLink

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LG220 Application for Exempt Permit Organization Name L,".,...J"Ii?~~ l..-\ct->.? Local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I acknowledge this application. Check the action that the city is taking on this application. O The city approves the application with no waiting period. O The city approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city) . o The city denies the application. Print name of city Signature of city personnel receiving application Title Date_'_'_ Page 2 of 2 2'06 ~ws r If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county is taking on this application. O The county approves the application with no waiting period. o The county approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days. o The county denies the application. Print name of county Signature of county personnel receiving application Title Date_'_'_ TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limi1s. [A township has no statutory authority to approve or deny an application (Minnesota Statute 349.213, subd. 2).] Print name of township Signature of township official acknowledging application Title Date--1_'_ Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge. I acknOWledge that the financial report will be completed and returned to the Gamblin . ontral Board within 30 days of the date of our gambling activity. Name (please print) Date /,}- I i)- i..- I c' Cc. Complete an application for each gambing activity: . one day of gambling activity . two or more consecutive days of gambling activity . each day a raffle drawing is held Mail Application and Attachments Send . the completed application, . a copy of your proof of nonprofit status, and . a $50 application fee. Make check payable to "State of Minnesota"). To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113