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Page of 2 Application for Exempt Permit LG220 10/98 Organization Name f Local Unit of Government Acknowledgment (REquired by Statutel 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, ! 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 day 30 days (60 days for a first class city). 2. Waive the above-noted waiting period: The couni 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 personnei receiving application) Print name of .ty: Title 11 La Date .1 __ _.�-_v�,•_] A Own On behalf of the township, 1 acknowledge that the (Signature of city personnel receiving application) organization is applying for exempted gambling activity within the township limits. Title �nU-r�� R t-- 5 Date I ► , A township has no statutory authority to approve or den! � -�-� -�--- ------ an application (Minn. Stat. sec. 349.273, subd. 2). Print name of township: E ure of township official acknowledging application) I Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge.- Chief Executive Officer's signature �;� �� .�;-�� '�`�-�� Date r � �;,��., Name(please pant} �..�..�.,. 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.