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Jul 25 02 013: 1 Oa <br /> EARNERS INS 6122432779 p. 3 <br /> 2 <br /> LG220•Application for Exempt Permit Page 2 of <br /> Organization Na1"n @ .�:.�.��—�� �"?�� �� ,�ci�� ����-- <br /> Local Unit of Government Acknowledgment <br /> If the gambling premises is within city Ifmits, the the gambling premises is located in a township, botq <br /> city must sign this application. tpe county and township must sign this application. <br /> On behalf of the city, I acknowledge this application,, ��n behalf of the county, I acknowledge this application. <br /> Check the action that Check the action that <br /> the city is taking on this application. the county is taking on this application. <br /> The city approves the application with no The county approves the application with no <br /> waiting period. waiting period. <br /> The city approves the application with a 30 day The county approves the application with a 30 da <br /> waiting period, and allows the Board to issue a • <br /> permit after 30 days 60 days for a first class ����� period, and allows the Board to issue a <br /> p Y ( Y permit after 30 days. <br /> city). <br /> The county denies the application. <br /> The city pp denies the application. <br /> Print name of city_....-...... •_ ...�.__.�-_.,.�, ,R«.�_...M.r..., j'nnt name of county M a - - -- - - - - - - - - <br /> (Signature of city personnel receiving application) ;Slgnatureofcounty personnel receiving application) <br /> Me <br /> e- - - - - I - - - - - - - - - - - - a - <br /> - t <br /> TOWNSHIP: On behalf of the township, I acknowledge that <br /> i he organbtian is applying for exempted gambling activity <br /> Nnin the township limits.[A township has no statutory <br /> authority to approve or deny an application (Mmn. Stat. sec. <br /> 349.213, subd. 2).] <br /> Print name of township ..�.�� �..„�.. ., 4.,. _. <br /> ID ignature of township official acknowledging application) <br /> ate - - - L - - J - - . <br /> Chief Executive Officer's Signature <br /> The information provided in thiappliGation is cc i iete and accurate to the best of my knowledge. <br /> 'Chief executive officeNgnature ._ - - - - - - - - <br /> T Name lease rint rr` � 17gaId date ' <br /> Mail Application and Attachments <br /> At least 45 days prior to your scheduled activity date send: <br /> the completed application, If your application has not <br /> 4 a copy of your proof of nonprofit status, and been acknowledged by the <br /> a $25 application fee (make check payable to "State of Minnesota"). local unit of government or <br /> Application fees are not prorated, refundable, or transferable. has been denied, do not <br /> Send to: Gambling Control Board send the application to the <br /> 1711 West County Road B, Suite 300 South Gambling Control Board. <br /> Roseville, MN 55113 <br />