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<br />---------- - -~~-~--------~-~-~---~------- -- -~~- ~------ ----- <br /> <br />. .. <br /> <br /> <br />LG220 Application for Exempt PermIt <br /> <br />Page 2 of2 <br />4If17 <br /> <br /> <br />If the gambling premises Is within city Dmlts. <br />the city must sign this application. <br />Cheok (~ the action tbat the oily Is taking 011 <br />this application. <br />The appIk:a1ion Is acIcnowIedged with no waiting period. <br />The appllca1ion Is acIcnowIedged with a 30 day waiting <br />period. end allows the BoertI to issue a permit after 30 <br />days (60 days tbr a 1st class cI1J). <br />The eppIication Is denied. <br /> <br />If the gambling premises Is located In a township, both <br />the county and tDwnshIp must sign this ~ <br />Check (~the action tbattheaountr Is taking on <br />tIlls~ <br />_The epplIcetIon is adcnowtodged with no welting period. <br />_The eppIIc8tlon is ecIcnow!edged with a 30 day waiting <br />period. end allows 1he BoertI to Issue a permit after 30 <br />days. <br />_The appIlcation Is denied. <br /> <br />Print name of city <br />On behelfofthe ~ I adtnowIedge this eppI1r.alion. <br />S\gn81LIre of cI1J p8I8OM8I rec:eivlng applIoation <br /> <br />Print name of countv <br />On beheIIofthe ~ I edmowledge this eppf1Galion. <br />SIgnalur8 of countv personnel receiving application <br /> <br />TItle <br /> <br />08t8---1---1_ <br /> <br />TltIe Dale_' ,- <br />TOWNSHIP: On behlllfoflhe townsIJIp,/adcnowIedgeth8tthe <br />organization Is applying forexempted gambling adIvIly wIlhIn the <br />township 1Im\l8. [A township has no statutory authorily to approve <br />ordeny an appIIca1Ion(MlnnesOta Statute 349.213, subd. 2).] <br />Print name of township <br /> <br /> <br />Signature of township oflidal acknowIadging application <br />TItle Dale _'---1- <br /> <br />Name (please print <br />Complete an application for each gambIng adMty: <br />.. ona day of gambling actMty <br />.. two or more consecutive days of gambUng aclivity <br />.. each day a raftIe drawing Is held <br />Send with 1he compIel8d application: <br />.. a copy of your proof of nonprofit status. and <br />.. $50 appIlca1Ion fee. Make check payable to <br />"Slate of MInnesota". <br /> <br />Date Db I.fJ..1JE <br />financial report and recordkeepln9 required <br />A financial report form and inslructions will be sent wilh yoW' <br />pennIt WIhIn 30 days of your date of ~ 1he fil'l8l'\Clial <br />report form must be compIetBd and returned to the Gambling <br />Control BoertI. <br />Questions? <br />Call the UcensIng Section of 1he Gambling Control Board <br />at 651~78. <br /> <br /> <br />To: Galllblq Control Board If you use a1TY. c:all1he BoertI by using the MInnesota Relay <br />1711 West CoW'lty Road 8, SUite 300 South ServIce and ask to pIac:e a caD to 651-639 1000. Or. check <br />Rose. UN 65113 our web site at ww.:.gcb.stata.mn.us. <br /> <br />Data ~ Thlstblm". nBCIe avaIIabJD In Your Il8m8 and 8111I your ~A.dk..ls Il8IIIl Board IIIllIdIeJ8. ... of the Board -- WDIk <br />fomIIt (Le.1aIge print. BraIlle) upon and addfess wID be public information wilen ~".lllIIlRlqUlnlslhattheyhlM llOCllIiStDthe <br />RlqUIIl 1h8 Wc.....a.n ........ on IIlIs tbIm I8CIIIVed br the I3DaId. NJ the oIher rnr......6.n tub......; the M!nrIIIIJta ~rlhlllllt of PubIlc <br />(and any atlaGllrnelllS) wiD be used by the Ihat you provide wi be pdvate dlIIa about you Safety; the MInneSota A1lomay General; the <br />0llIlInlI8DaId(Baanl)to.......ih.your unIII the Board .... your pemIIt. Wten tha MInnesota CrH..,dulclners of AdmbM.&un. <br />tD belJwolwd In IawruI gambling Board Issues your pem8. aD of the Itdi:...QIIon FInanoa.andRevenue;thaMlmesalaLeglslldlve <br />klMInrleBaIa. Youhawtha"refuse lhatyouhIMprovidecItotheBaardlnthepnlCl8SS Audllor. national and international gambling <br />suppIf the hM,1ldIon aqulsli ~ hDWlMlr, If of ~ forJOW' ptldwll bllcDrI'I8 public. If reguIatDIy agencies; .... puISUIIlt tD court <br />refuse to ..1hI8 1t1fcA....... the Baard the Board does not Issue you a pmrit, aD tha order; o1h8r IndMdvaIs and agencies that are <br />IIIIY not be abI8 to .....,1Im your qI,...dlR..A"\S IrfonnItIDn you have plQ'IIded In the pIQC8SS of specIIIcaIIJ auIJtoItIed .. &tat8 or federal law to <br />as a consequenca. may __ tD Issue you ~ for a penrit remains private. with tha have 8Oll8S8 tD the 1nformdIDn: IncIIvIdI.BIs 8111I <br />a penriL If you supply the ~"olIlIon AIql~ excepIIDn of your Il8II8 8111I your _iddIDtI's agenIlIlls for Wdch law or IBgaI Older llUlttorilIIBs <br />Board" be abI8 to JIl'OCIlS8 your awl.alloh. narrra8l1lladdnlss........l8I'IIIinpublc. PItvaID a new use or sharing of 1td'"...l1IlIon after this <br />dlIIa are available to the NotIl:e was . 8111I with consent. <br /> <br /> <br />33b <br /> <br />------------ ----- ------------------- ----- - -- <br />