2009-12-29 CC Packet - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of 2 7109 N ct ni t5 bTERM ENt KNOWtWGMENtk ., r r.- R .�. } C t I , if the gambling premises Is within city limits, N the gambling premises is located In a township, a a dty official must check the action that the city Is county official must check the action that the county is taking taking on this application and sign the application. on this application and sign the application. A township official is not required to sign the application. The application Is acknowledged with no waiting period. The application is acknowledged with no waiting period. 1 The application is acknowledged with a 30 day waiting The application Is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 per. and allows the Board to issue a pemkk after 30 days (60 days for a lst dens city). days. The application is denied. She application is denied. Print city Print county name ty dame On behalf of the county, I acknowledge this application. On behalf of the city, 1 acknowledge this application. Signature of county official receiving application Signature of city official receiving application Title Date / / ! (Optional) TOWNSHIP: On behalf of the taanship, 1 Title Oslo l f acknowledge that the organization is applying for exempted gantlI ng aagvky within township Omits. (A township has no statutory authority to approve or deny an application (Minnesota Statute 349.160 Print township name Signature of township official admowledging application Title Date i / The information provided in this application is .. plete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and retu • the ,_ • with' 0 days ` the date of our gambling activity. Chief executive officer's sign: • •r.A:. _ / Date /2/w/09 Complete a separate application for each gambing activity: Financial report and recohdkeeping rag !red - one day of gambling activity, A financial report form -taro or more consecutive days of gambling activity, y �i use the and onllne 011-in available at - each day a raffle drawing is held www.gdt.state.mn.us. Within 30 days of the activity date, Send application with: complete and return the financial report form to the • a copy of your proof of nonprofit status, and Gambling Control Board. ▪ application fee for each event Questions? Make check payable to "State of Minnesota." Call the Licensing Section of the Gambling Control To: Gambling Control Boats Board at 161 - 6344076. 1711 West County Road B, Suite 300 South Roseville, MN 65113 r Q' �.:tk' #�'. Data privacy. This form Mil be made available the Board will be able to process Your Board stag whose work requires access to the In alternative format (La large prim, Braille) appli anon. Your nemo and and your Information; Minnesota's Department of Public upon request The information requested on argsnization's name and address will be public Safety, Attorney General; commissioners of this form (end any attachments) will be used by IMmmation when reGNved by to Board. M Admtdatation, Finance, and Revanua the Gambling Control Board (Board) to the other information you Provide oil be Private Legislative Auditor. national and international determine your quaIdieatbns to be imdved in dale until the Board issues your permit. When g anbgng Hatay agencies: anyone pursuant lawful gambling activities In Minnesota. You the Board lasues YoUr permit, all of We to coat order, otherindWlduals end agencies have the right to refuse to supply the information provided to the Board wit become that are spedliraly sawing by mess or Information requested; however, if you refuse to Pubic. tithe Board does not Moue a Pella an federal law to have accuse to the hlfoirnation; supply this information, the Board may not be Information provided remains Ovate, widn the Individuals and agendas for which law or legal able to determine your quaOficatiom and, as a exception of your name and Your oraantzauon's order sulhaizea a new use or sharing of consequence may refuse to issue you a permit name and address which cull remain pudic. Information after this Nonce was given; and if you supply the information requested, Private data are available to: Board members, anyone with your consent 36