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<br />LG220 Application for Exempt Permit <br /> <br />Page 2 012 <br />6108 <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 (-.J) the action thet the city Is taking on Check (-.J) 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 10 issue a perm~ after 30 period, and allows !he Board to issue a perm~ after 30 <br /> days (60 days for a 1st dass ~). days. <br /> _The appl;cation is denied. <br />_The application ;s denied. <br />Print ~ name Print county name <br /> On behalf of the county, I acknowledge this applica/jon. <br />On behalf of the city, I acknowledge this application. Signature of county personnel receiving application <br />Signature 01 ~ personnel roceiving application <br /> Tme Date I I <br />Title Date----1----1_ TOWNSHIP: On behalf of the township, J acknowledge that the <br /> organiza/jon is applying for exempted gambling actMtywithin the <br /> townsMp limits. [A township has no statutory autholity to approve <br /> or deny an application [Minnesola statute 349.213, sulld. 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 financial report will be completed and returned to the Board ~ithin 30 days of the date of our gambling activity. <br /> '\i (' -~U <br />Chief executive officer's signature )( <>-.f\~lil-1 ''''0 "Ill. Date 0 'f I 17 I () "l <br />Complete an application for ead1 gambing activity: to Financial report and recordkeeplng <br />. one day of gambling activity required <br />. two or more consecutive days of gambling activity A financial report form and ins!ructions will be <br />. ead1 day a raffle drawing is held sent with your permit. Wthin 30 days of !he <br />Send application with: activ~ date, complete and retum 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 d1eck payable to "State of Minnesota." Ca" !he Licensing Section of the Gambling <br />To: Gambling Control Board Control Board at 65 HI39-4076. <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 altemaliw fo<mat Q.e. Ialge ptint, ~> upon <br />request The information requested on this <br />form (and any _> will be used by \he <br />Gambling ConlroI Boanl (8oo1ll) 10 de!em1ine <br />your quaflficalions 10 be invoIIIl!!d in tawruI <br />gambling adMJies in MinnesoIa. You have \he <br />right 10 refuse 10 S<.WiY \he inIoonaIion <br />requested; h<Jv..oevef, W you refuse 10 S<.WiY <br />this inIom1aIion, \he 8oo1d may not be _10 <br />de!em1ine your qua/illcations and, as a <br />consequen<:e, may refuse 10 issue you a <br />pemit. "you supply \he information requested. <br /> <br />1he Board will be able 10 process your <br />application. Yo<s name and and your <br />OllIBl12ation's name and address will be IUlIlc <br />infoonation when _ by \he Board. !'JI <br />\he oIher InIormation you provide will be pIivafe <br />data 1IlIiI\he Board issues your pemit. IM1en <br />\he Board issues your pem1lt, all of IIle <br />infoonation provided to the 800m willbecoo1e <br />puIlIic. "the Board does not issue a pemit, aI <br />infom1ation provided remains prlvaIe. wIIh IIle <br />exception of your name and yo<s ocgan/zaIion's <br />name and address v.IlIch will remain pUJIic. <br />_ data are available to: Board rnembefs. <br /> <br />Board staff wl10se WO<1< requires aeoess to <br />!he 1nIormation; MinnesoIa's Depanment of <br />Public SaIoIy; AItomey GenetliI; Cormissionenl <br />of_. Flnarce, and Revenue; <br />LegisJaliveAudltor. national and_I <br />gambfing regUatory agencies: anyone pusuanI <br />to cout omer. oIher _ and agencies <br />lhal are specilicaIIy aulhorized by state or <br />federal law to have aeoess 10 !he inbmation; <br />individuals and agencies lor v.IlIch law or legal <br />order aUhorizes a new use or shariI"g 01 <br />inlormation _this NolIoo was given: and <br />anyone wIIh your consent <br />