Laserfiche WebLink
<br />--- - --------- - - -- - ---- <br /> <br />----------- ------- <br /> <br />J"'\ <br /> <br />LG220 Application for Exempt Pennit <br /> <br />Page 2 of 2 <br />4107 <br /> <br />L~AL UNIT OF GOVERNIIIENTA~KNQWLED~N1J:NT . . .H . ., . ...... <br />If the gambling premises Is within city limits, If the gambling premises Is located In a township, both <br />the city must sign this application. the county and township must sign this application. <br /> Check c-"> the action that the city Is taking on Check <,J> the action that the county Is taking on <br /> this application. this application. <br />_The application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. <br />_The application is acknowledged with a 30 day waiting ~The application is acknowledged with a 30 day waiting <br /> period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 <br /> days (60 days for a 1st class city). days. <br /> _The application is denied. <br />_The application is denied. <br />Print name of city Print name of county <br />On behalf of the county, I acknowledge this application. <br />On behalf of the city, I acknowfedge this appUcation. Signature of county personnel receiving application <br />Signature of city personnel receiving application <br />Title Date_I----1- Title Date I 1- <br /> TOWNSHIP: On behalf of the township, I acknowledge that the <br /> organization is applying for exempted gambling activity within the <br /> township limits. [A township has no statutory authority to approve <br /> or deny an application (Minnesota Statute 349.213, subd. 2).] <br /> Print name of township <br /> Signature of township official acknowledging application <br /> Title Date I I <br />CHieF EXJ=CUTIVE: OFFICERiSSIGNATUR.E '. :. . ..... ....<:. ..... <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 Board within 30 days of the date of our gambling activity. <br />Chief executive officer's signature <br />Name (please print) Date J I <br />Complete an application for each gambing activity: Financial report and record keeping required <br />. one day of gambling activity A financial report form and instructions will be sent with your <br />. two or more consecutive days of gambling activity permit Within 30 days of your date of activity the financial <br />. each day a raffle drawing is held report form must be completed and retumed to the Gambling <br />Send with the completed application: Control Board. <br />. a copy of your proof of nonprofit status, and Questions? <br />. $50 application fee. Make check payable to Call the Licensing Section of the Gambling Control Board <br /> "State of Minnesota". at 651-639-4076. <br />To: Gambling Control Board If you use a TTY, call the Board by using the Minnesota Relay <br /> 1711 West County Road B, Suite 300 South Service and ask to place a call to 651-6394000. Or, check <br /> Roseville, MN 55113 our web site at www.gcb.state.mn.us. <br />Da1a privacy. ThIs form wBI be made avaDabIe In Your name and and your organization's name Board members, staff of the Board whose work <br />aJtemalive format Q.e. large print. BraIDe) upon and address will be public information when assignment requires that they have access to the <br />request. The information requested on this form received by the Board. AD the other Informallon 1nfonnatIon; the Minnesota Department of Public <br />(and any attachments) will be used by the that you provlde wBI be private data about you Safety; the Minnesota Attorney General; the <br />. GambBng Control Board (Board) to determlneyour untO the Board issues your permit. When the Minnesota Commissioners of Administration, <br />. qualllicatlons to be JnvoIvedIn IawfuJ gambling Board Issues your permit, aD of the lnfonnallon Anance, and Revenue; the MInnesota legislative <br />acIlviIiesin MInnesota. You have the rlghtto refuse that you have proWled to the Board In the process Auditor, national and international gambling <br />. to supply the Jnfonna1lon requested; however, If of applying for your pennit wm become pubDc. If regulatory agencies; anyone pursuant to court <br />you refuse to supply this lnfonnation, the Board the Board does not Issue you a pennlt, aD the order; other Individuals and agencies that are <br />may not be able to detennlne your qualifications information you have provlded In the process of speciflcaBy authorized by state or federal law to <br />and, as a consequence, may refuse to Issue you applying for a permit remains private, with the have access to the information; individuals and <br />. a permit. If you supply the lnfonnation requested. exception of your name and your organization's agencles for which law or legal order authorizes <br />the Board wm be able to process your application. nameandaddresswhlchwBIremalnpubllc.Prlvate a new use or sharing of Information after this <br />data about YOU are available onlY to the foIIowIr1Q: Notloe was alven' and anyone wi1h vour consent <br /> <br />33D <br />