2005-05-25 Set Agenda - Laserfiche WebLink

Home Browse Search

LG220 Application for Exempt Permit Organization Name {'.F 1oJTe;:.tt. '\I \ \...-l.R_ Local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I acknowledge this application. Check the action that the city is taking on this application. O The city approves the application with no waiting period. O The city approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city). o The city denies the application. Pnnt name of city Signature of city personnel receiving application litle Date_I---..!_ . L\t:>!..lS CLL{.e, Page 2 of 2 11/04 If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county is taking on this application. o The county approves the application with no waiting period. o The county approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days. o The county denies the application. Print name of county Signature of county personnel receiving application litle Date_I---..!_ TOWNSHIP: On behalf ofthe township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. [Atownship has no statutory authonty to approve or deny an application (Minnesota statute 349.213, subd. 2).] Print name of township Signature oftownship official acknowledging application Title Date---..!----.l_ Chief Executive Officer's Signature The Information provided in this application 's complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and ret ed to the Gamb ing Control oard within 30 days of the date of our gambling activity. () Chief executive officer's signature ~ ' Name (please print) :::r 0 ~/'J t-J. T \,.><\ \..l,. Mail application and attachments Complete an application for each gambling activity: one day of gambling activity two or more consecutive days of gambling activity each day a raffle drawing is held Dale~ -z.o 105 Send: the completed application, a copy of your proof of nonprofit status (see instructions), and a $50 appiication fee. Make check payable to "state of Minnesota". To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113