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LG220 Application for Exempt Permit Page 2 of 2 2/07 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the gambling premises is located in a township, both the city must sign this application. the county and township must sign this application. Check ("'J) the action that the city is taking on Check C") the action that the county is taking on this application. this application. _The application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day waiting _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 days (60 days for a 1 st class city). days. _The application is denied. _The application is denied. Print name of city Print name of county On behalf of the county, I acknowledge this application. On behalf of the city, I acknowledge this application. Signature of county personnel receiving application Signature of city personnel receiving application Title Date~~_ Title Date I I TOWNSHIP: On behalf ofthe 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 (Minnesota Statute 349.213, subd. 2).] Print name of township Signature of township official acknowledging application Title Date I I CHIEF EXECUTIVE.. OFFICER'S SIGNA TURE .. .... --:c 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 thyoard within 30 days of the date of our gambling activity. ChiefexecutiveOfficer'SSignat~ ? / ....--7 r , . Name(pleaseprint)--r~c6 II- 5~v~ *-. Date ..3 I 2e:J I 6? Complete an application for each gambing activity: Financial report and record keeping required . one day of gambling activity A financial report form and instructions will be sent with your . two or more consecutive days of gambling activity permit. Within 30 days of your date of activity the financial . each day a raffle drawing is held report form must be completed and returned to the Gambling Send with the completed application: Control Board. . a copy of your proof of nonprofit status, and Questions? . $50 application fee. Make check payable to Call the Licensing Section of the Gambling Control Board "State of Minnesota". at 651-639-4076. To: Gambling Control Board If you use a TlY, call the Board by using the Minnesota Relay 1711 West County Road B, Suite 300 South Service and ask to place a call to 651-639-4000. Or, check Roseville, MN 55113 our web site at www.gcb.state.mn.us. Data privacy. This form will be made available in Your name and and your organization's name Board members, staff of the Board whose work altemative format (Le. large print, Braille) upon and address will be public information when assignment requires that they have access to the request. The information requested on this form received by the Board. All the other information information; the Minnesota Department of Public (and any attachments) will be used by the that you provide will be private data about you Safety; the Minnesota Attorney General; the Gambling Control Board (Board) to determine your until the Board issues your permit. When the Minnesota Commissioners of Administration, qualifications to be involved in lawful gambling Board issues your permit, all of the information Finance, and Revenue; the Minnesota Legislative activities in Minnesota. You have the rightto refuse that you have provided to the Board in the process Auditor, national and international gambling to supply the information requested; however, if of applying for your permit will become public. If regulatory agencies; anyone pursuant to court you refuse to supply this information, the Board the Board does not issue you a permit, all the order; other individuals and agencies that are may not be able to determine your qualifications information you have provided in the process of specifically authorized by state or federal law to and, as a consequence, may refuse to issue you applying for a permit remains private, with the have access to the information; individuals and a permit. If you supply the information requested, exception of your name and your organization's agencies for which law or legal order authorizes the Board will be able to process your application. name and address which will remain public. Private a new use or sharing of information after this data about vou are available onlv to the followin~: Notice was given; and anyone with vour consent. /9