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LG220Appllcation for Exempt Permit Page 2 of 2 6/07 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 <.J> the action that the county Is tekJng on this application. this appUcatlon. _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 city name Print county name 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 I I Title Date ---1---1_ TOWNSHIP: On behalf of the 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 township name Signature of township official acknowledging application Title Date ---1--1 CHIEF exECUTIVE OFFICER'S SIGNATURE The Information provided in this apPlica:;fJ comPlete~~ accurate to the best of my knowledge. I acknowledge that the financial report will be completed an tumed tOA oard within 3.Q.1ays of the date of our gambling activity. Chiefexecutiveofficer'ssignature--T k .,e-- Date 30 I h I Df( Complete an application for each gamlilng activity: Financial report and recordkeeplng . one day of gambling activity required . two or more consecutive days of gambling activity A financial report form and instructions will be . each day a raffle drawing is held sent with your permit. Within 30 days of the Send application with: activity date, complete and return the financial . a copy of your proof of nonprofit status, and report form to the Gambling Control Board. . $50 application fee for each event. Questions? Make check payable to "State of Minnesota." Call the Ucensing Section of the Gambling To: Gambling Control Board Control Board at 651-639-4076. 1711 West County Road B, Suite 300 South Roseville, MN 55113 DaIa privacy. This form will be made available In alternative format p.e. large print, BraiDe) upon request The Information requested on this form (and any atlachmenls) will be used by the Gambling Control Board (Board) fo determine your qualifications to be Involved in IawfuJ gambling activities in Minnesota. You have the right to refuse to supply the Information requested; however. n you refuse to supply this information, the Board may not be able to determine your quafdications and. as a consequence, may refuse to issue you a perm~. If you supply the Information requested, the Board will be able to process your application. Your name and and your organization's name and address wiD be pubUc information when received by the Board. AU the other Information you provide will be private data untIJ the Board issues your pennit When the Board issues your permit, aD of the Information provided to the Board will become public. If the Board does not issue a permit, aD Information provided remains private, with the exception of your name and your organization's name and address which wIU remain pubRc. Private data are available to: Board members, Board staff whose work requires access to the information; Minnesota's Department of PubUc Safety; Attomey General; CommIssloners of Administration, Rnance, and Revenue; legislative AudItor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are speciflcally authorized by stale or federal law to have access fo the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.