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<br />" <br /> <br />Application for Exempt Permit - LG220 <br /> <br />Organization Name <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises is within city limits, the <br />city must sign this application. <br />On behalf of the city, I acknowledge this application. <br /> <br />Page 2 of 2 <br />8'00 <br /> <br /> <br />Name (please print) <br /> <br />Mail Application and Attachments <br /> <br />At least 45 days prior to your scheduled activity date send: <br />. the completed application, <br />. a copy of your proof of nonprofit status, and <br />. a $25 application fee (make check payable to "State of Minnesota"). <br />Application fees are not prorated, refundable, or transferable. <br /> <br />Send to: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />RoseviJIe, MN 55113 <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_'_' <br /> <br />Chief Executive Officer's Signature <br />The information provided in this applica 'on is com <br /> <br />. <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_'_'_ <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 (Minn. Stat. sec. <br />349.213, subd. 2).] <br /> <br />Print name of township <br /> <br />(Signature of township official acknowledging application) <br />Title <br />Date~_'_ <br /> <br />ccurate to the best of my knowledge. <br />. 'to. <br />, <br /> <br />Date 0,:; l-..f:!LiB- <br /> <br />If your application has not <br />been acknowledged by the <br />local unit of govemment or <br />has been denied, do not <br />send the application to the <br />Gambling Control Board. <br />