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Page 2 of 2 Application for Exempt Permit - LG220 10/98 Organization Name Local Unit of Government Acknowledgment (Required by Statute) If the gambling premises is within city limits, the If the gambling premises is located in a township, both city must sign this application. the county and township must sign this application. 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) Title Print name of city: Date / / . On behalf of the township, I acknowledge that the (Signature of city personnel receiving application) organization is applying for exempted gambling activity within the township limits. Title 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 applic tion is compete and ccurate to the best of my knowledge. r /II l .Th Chief Executive Officers signature "L 0 -- "JU !' 1 i Name (please print) I nL � L ) 1 � 4�- Y IA Date e/ti l r' w l 0 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 government, do not send the application to the Gambling Control Board.