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<br />LG220 Application for Exempt Permit <br /> <br />Page 2 of 2 <br />6/08 <br /> <br />LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT <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 t") the action that the city is taking on Check (V) 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 dass city). days. <br /> _The application is denied. <br />_The application is denied. <br />Print city name te.nte.:rv\llt Print county name <br /> On behalf of tbe county, I acknowledge this application. <br />On behalf of the city, I acknowledge this application. Signature of county personnel receiving application <br />Signature of city personnel receiving application <br /> Title Date-l-l_ <br />Title Date-l_I_ 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 township name <br /> Signature of township official acknowledging application <br /> Title Date I I <br />CHIEF EXECUTIVE OFFICER'S SIGNATURE <br />The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that <br />the "nanci.1 report wHl be completed .nd~ lumed 10 "Yf08fd ril1il}.J!' dayiS the date of our gambling .clivity. <br />Chiefexecutiveofficer'ssignature I\. - ~~ . III 0 ~\ Date OrJ.. I () 11 Of <br />Complete an application for each gambing activity: t J Financial report and recordkeeping <br />. one day of gambling activity required <br />. two or more consecutive days of gambling activity A financial report form and instructions will be <br />. each day a raffle drawing is held sent with your permit. Within 30 days of the <br />Send application with: activity date, complete and return the financial <br />. a copy of your proof of nonprofit status, and report form to the Gambling Control Board. <br />. $50 application fee for each event. Questions? <br /> Make check payable to "State of Minnesota." Call the Licensing Section of the Gambling <br />To: Gambling Control Board Control Board at 651-639-4076. <br /> 1711 West County Road B, Suite 300 South <br /> Roseville, MN 55113 <br /> <br />Data privacy. This form will be made available <br />in alternative format (i.e. large print, Braille) upon <br />request. The infOlTnation requested on this <br />form (and any attadlments) will be used by the <br />Gambling Control Board (Board) to determine <br />your qualffications to be involved in lawful <br />gambling activities in Minnesota. You have the <br />right to refuse to supply the information <br />requested; however, if you refuse to supply <br />this information, the Board may not be able to <br />determine your qualifications and, as a <br />consequence, may refuse to issue you a <br />permit. If you supply the information requested, <br /> <br />the Board will be able to process your <br />application. Your name and and your <br />organization's name and address will be public <br />information when received by the Board. All <br />the other information you provide will be private <br />data until the Board issues your permit. IM1en <br />the Board issues your permit, all of the <br />information provided to the Board will become <br />public. If the Board does not issue a permit, all <br />information provided remains private, with the <br />exception of your name and your organization's <br />name and address which will remain public. <br />Private data are available to: Board members, <br /> <br />Board staff whose wor!< requires access to <br />the infonnation; Minnesota's Department of <br />Public Safety; Attorney General; Commissioners <br />of Administration, Finance, and Revenue; <br />Legislative Auditor, national and intemational <br />gambling regulatory agencies; anyone pursuant <br />to court order; other individuals and agencies <br />that are specifically authorized by state or <br />federal law to have access to the information; <br />individuals and agencies for which Jawor legal <br />order authorizes a new use or sharing of <br />information after this Notice was given; and <br />anyone with your consent. <br /> <br />I <br />I <br />I <br /> <br />L_ <br /> <br />35~ <br />