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Page 2 of 2 ' Application for Exempt Permit - LG220 10/98 Organization Name Church of St. Genevieve Local Unit of Government Acknowledgment (Required by Statute) lithe tth remises1sa 01 *:11 , M e" if the g ambhngyp es s ?3acated iel4#o tooth cit m nsts7jtrlth t appli '� , (' ,'ti i 1 ya,„, . the coopoi ate "d #owr ip _sT "n it On behalf of the city, I acknowledge this application On behalf of the county, I acknowledge this application and three options for the city: and three options for the county: 1. Approve the application: By taking no action, 1. Approve the application: By taking no action, the the city allows the Board to issue a permit after county allows the Board to issue a permit after 30 days. 30 days (60 days for a first class city). 2. Waive the above -noted waiting period: The county allows the Board to issue a permit before 30 days. 2. Waive the above -noted waiting period: The Documentation attached. city allows the Board to issue a permit before 3. Deny the application by passing a resolution within 30 days (60 days for a first class city). Docu- 30 days. mentation attached. Print name of county: 3. Deny the application by passing a resolution within 30 days (60 days for a first class city). (Signature of county personnel receiving application) Print name of city: City of ('antPrvi 11a Title Date / / (Signature of city personnel receiving application) On behalf of the township, I acknowledge that the Title organization is applying for exempted gambling activity within the township limits. Date / / A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). Print name of township: (Signature of township official acknowledging application) Title Date / / Chief Executive Officer's Signature The information provided in this applicatiorda complete and accurate fti the best of my knowledge. Chief Executive Officer's signature ( � rile? �/ /' Name (please print) Richard J.' Wolter Date 3 / 3 / 99 Mail Application and Attachment(s) At least 45 days prior to your scheduled activity date send: • the completed application; • a copy of your proof of nonprofit status, and • a $25 application fee (make check payable to "State of Minnesota "). Application fees are not prorated, refundable, or transferable. Send to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 If your application has not been acknowledged by the local unit of govemment, do not send the application to the Gambling Control Board.