Laserfiche WebLink
<br />I <br /> <br /> <br />If the gambling premlsea is within city limits, <br />a city official must check (X) the action that the <br />city is laking on this appllcallon and sign the <br />application. <br /> <br />_The application is acknowledged with no waiting period. <br />_The application is acknowledged with a 30 day wailing <br />period, and allows the Board to issue a permit after 30 <br />days (60 days fora1s1 cl... tily). <br />_The apptication is denied. <br /> <br />Print city name <br />On behalf of tho city, I saknowlodgo this oppJicalion. <br /> <br />Signature of city official mce1ving application <br /> <br />Tille <br /> <br />D~----1----1_ <br /> <br />CHIEF EXECUTIVE OFFICER'S SIGNATURE <br /> <br />Page 2 of 2. 9108 <br /> <br />DG NT <br /> <br />If the gambling premises Is located In a township, a <br />county official must check (X) the action that the county <br />is 'tIking on this application and sign the application. A <br />township official must also sign the application. <br /> <br />_The application Is acknowledged with no walling period, <br />_The application is acknowledged with a 30 day waiting <br />period, and aUowa the Board to issue a pennit oller 30 <br />doy.. <br />_ Tha application i. denied. <br />Print county nome <br />On behalf Of tho county, I ar;/<nOWletJge this applicalfon <br />Signature of county offiCial receiving application <br /> <br />Title <br /> <br />Date <br /> <br />TOWNSHIP: On behalf of the toWnship. I acknowtedge thaI <br />the organiZation is applying for exempled gambling actiVIty <br />wfthln township limits, [A township has no statutory authority to <br />approve or deny an applcation [MiMoso/a Statute 349.213.lillbd. 2)J <br />Print township name <br /> <br />Signotule of _ip official acknoWledging applicalion <br /> <br />Title <br /> <br />Dale <br /> <br />Tho information providad in this applicalion Is complote anctBccurato to th8 best of my knowlsctge. I acl<nowladge that the <br />financial re{XNt will be completed and reW /0 th rei within 30 days of th8 date of our gambling activity. <br /> <br />Chief executive oflice(ssignature Date J /17 o. <br /> <br /> <br />Complete a aeparate appllcallon for each <br />" one day of gambling aclMty. <br />.. two or more consecutive days of gambUng activity, <br />_ each day a raffle drawing I. held <br /> <br />Send application With: a oopy of your proof of nonp,ofrt stalus, <br />and $50 opp\ieaUon fee for each event Make checI< payable 10 <br />"Slate of Minnesota." <br /> <br />To: Gambling Control Board <br />1711 WestCounly Road B. Suile 300 South <br />RoSOlliIe, UN 55113 <br /> <br />Financial report and recordkeeping <br />required <br />A financial report fonn and instructions will be <br />sent with your permit. Within 30 days of the <br />activity date, complete and return the financial <br />report 10111110 the Gambling Control Board. <br />Queetions? <br />CaB the ticenslng Section of the Garl'llling <br />Control Board 01651-639-4076. <br /> <br />~~~~ -~~ ' <br />- ,~~~- ""- <br /> <br />~~.g~~ <br /> <br />Data privacv_ This form wII be made avei~e the Boan:f will be able to proee&S your <br />In aJtemative format (I.e. larve print, Bralla) applicetion. Your name and and your <br />upon request, The in1c:lrn1ation requested on organization'$ name and address wiI be public <br />this 'form (and any attadvnents) vAl be used by infDtma1lon'MlBn l1!CEIived by the Board. AI <br />tr.e GembUng Control Boart:t (Board) to the oIh~ jntorma~ YOll provide will ~ p11vate <br />detennine your qulltfiea1ions to be invotved In date until the Board ISSUes your permit. Wlen <br />I8wfuIgambling activi1ie$ in Minnesota. You the Board iswes your permit. aI dthe <br />have the right to refute tg auppCy the lnfarmQt10n pro\l\ded to the 8o8rd wi. bBcC)me <br />Infon'nl1tlon requestBd; hcMeVf!Ir, it you Jefuse to public. If the Board doea not iQu. a pemit, an <br />supply this information, the Boan:f m.v not be i~lrv.I'''1 PfO\Iidecl remaina priv8le. with 1M <br />ab&e to detennlne your qualification.t and. .. 8 exception of your hamB end ywr org&ftlizaIiofI's <br />consequence. ml1Y ~IO to iuue you II permit n~e and ~ which wflI remain pubic.. <br />If you supply the information 1eQU8SIed. PrNate data altll available to: Board memberS. <br /> <br />BoBrd steff whose WOf'k requires access to the <br />information; MinnoaotB'$ Department of Public <br />Srtfety: Anomey General; Commtsstoners of <br />MministratiOn. Finance, and Revenue; <br />LegiUtive Auditor I nationsl 8ftd intem4tionat <br />gambling reQulatOfY aveocie:s: 8n~ pursuant <br />to court order: other lndlviduab and egeneles <br />that are apecifican)' authorized by state or <br />federal Iew to have at:eeSS to the information; <br />InliViduM and ageodes for wtllc:h law Of legal <br />Older authotlzes . new use or ahJrlng of <br />ntormation after this Notice was gMln; and <br />anyone with your eonsent. <br />