2007-12-26 CC Packet - Laserfiche WebLink

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Page 2 of2 6/07 LG220 Application for Exempt Pennit LOCAl.UNITOF.OOVERNMENT.ACKNOWLEDGMENT If the gambling premises is within city limits, the city must sign this application. Check (~) tile action that the city is taking on this application. _The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a pennit after 30 days (60 days for a 1 st dass city). _The application is denied. Print city name On behaff of the city, I acknowledge this application. Signature of city personnel receiving application Title Date-1_'_ CHIEF EXECUTIVE OFFICER'S SIGNA JURE If the gambling premises is located in a township, both the county and township must sign this application. Check (..J) the acUon that the county Is taking on this application. _The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a pennit after 30 days. _The application is denied. Print county name On behaff of the county, I acknowledge this application. Signature of county personnel receiving application Title Date_,_,_ TOWNSHIP: On behaNofthe township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. [A township has no statutory authority to approve ordeny an application [Minnesota Statute 349.213, subd. 2)] Print township name Signature of township official acknowledging application TiUe Date _,_,_ The information provided in this applic8 .on is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed returned to Board within 30 cia s of the date of our gambling activity. Chief executive officer's signat 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 Send application with: · a copy of your proof of nonprofit status, and · $50 application fee for each event. Make check payable to "S1ate of Minnesota." To: Gambling Control Board 1711 'Nest County Road 8, Suite 300 South Roseville, MN 55113 Date i 1- , ),,-1 , Of Financial report and record keeping required A financial report form and instructions will be sent with your permit Wthin 30 days of the activity date, complete and return the financial report form to the Gambling Control Board. Questions? Call1he Licensing Section of the Gambling Control Board at 651-639-4076. Data privacy. This form wi be made available in alemative format O.e.large print, Bra.) upon request. The iriormation requested on this form <and any atlachments) wi be used by the Gambling Conlrot Board (Board) to ~.. ';'1IV your qualifications to be involved in IaY.fuI gambling activties in Mimesota. You have 1he right to refuse to supply the information requested; howaver, if you refuse to wppIy this information, the Board rmy not be able to detemWle your qualfications and, as a consequence, may refuse to issue you a pemit. If you supply the infonnation requested, the Board wi be able to process your application. Your name and and your organization's name and address \WI be public irIonnation Wlen received by the Board. ~ the other i 1v....Awn you pIVYide wiI be piwde data u~ the Board issues yow permI. Wlen the Board issues yow pemit, al dthe information provided to the Board wi beoome public. If the Board does not issue a permit, aI information provided remains private, vviIh the exoepion of your name and your organization's name and address YAlich wi remain pubic. Private data are available to: Board members, Board staff vvhose \YOrk requires access to the information; Milnesota's Department of Public Safety; Htomey General; Cormissioners of ,6drrinistration, Finance, and Revenue; Legislative AudiIDr, national and international garrtiing regulatory agencies; anyone pursuant to cowt order; other individuals and agencies that are specllcaly authorized by state or federal law to have aCIC:QSS to the information; individuals and agencies for 'Nhich law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent. 1J-