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<br />LG220 Application for Exempt Permit <br />Organization Name ?€~~.l...-L<.!" l..-l c,...I L\..-l--'\J. <br />Local Unit of Government Acknowledgment <br /> <br />Page 2 of2 <br />12103 <br /> <br />If the gambling premises is within city limits, the If the gambling premises is located in a township, both <br />city must sign this application. the county and township must sign this application. <br />On behalf of the city, I acknowledge this application. On behalf of the county, I acknowledge this application. <br /> Check the action that Check the action that <br /> the city is taking on this application. the county is taking on this application. <br />o The city approves the application with no o The county approves the application with no <br />waiting period. wailing period. <br />o The city approves the application with a 30 day o The county approves the application with a 30 day <br />waiting period, and allows the Board to issue a waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class permit after 30 days. <br />city). <br />o The city denies the application. o The county denies the application. <br />Print name of city Print name of county <br />(Signature of city personnel receiving application) (Signature of county personnel receiving application) <br /> Tille <br />Tille <br /> Date~~_ <br />Date~~_ TOWNSHIP: On behalf of the township, I acknowledge that <br /> the organization is applying for exempted gambling activity <br /> within the township limits. [A township has no statutory <br /> authority to approve or deny an application <br /> (Minnesota Statute 349.213, subd. 2).] <br /> Print name of township <br /> (Signature of township official acknowledging application) <br /> Trtle <br /> Date I I <br />Chief Executive Officer's Signature <br />The information provided in this appliG tion t..,comPlete and accurate to the best of my knowledge. <br /> j/ C) <br />Chief executive officer's signature ,II-\, [.,\"T,. <br />Name (please print) -.ipW ,/1 I h...~ rAe: Date b Ill:> I~ <br />Mail Application and Attachments <br />At least 45 days prior to your scheduled activity date send: <br />. the completed application, If your application has not <br />. a copy of your proof of nonprofit status, and been acknowledged by the <br />. a $50 application fee (make check payable to "State of Minnesota"). local unit of government or <br /> Application fees are not prorated, refundable, or transferable. has been denied, do not <br />Send to: Gambling Control Board send the application to the <br /> 1711 West County Road B, Suite 300 South Gambling Control Board. <br /> Roseville, MN 55113 <br />