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X0*19=0 6 - 6 1 41 XeT401-VIN Idle] ZT*]kV4-0ZLV,-F#Z I CTWNiL =*i 1114"Xil,14M If the gamblin, prem I ises is within c y limits, 9 a city official must check the action thiat the city is taking on this application and sign the apipilication. 44 .' .The appllicatiioin is acknowledged with no waiting period. The applicaton is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days, for a `1 st class city). ....The application is, denied. A Print city name (-�flu or -56-7 V, LtAI On behaff of the city ow • i t I acknlede this application. S�i�gnIature of city officia,l receiving application Page 2 of 2 11110 If the gambling premises is loicated fln a township, a county oifficial must check the action that the county is taking on thIis, application andl sign the apipllicaItioinI. A township official Is not required to sign the application. k The application is acknowledged with no waiting period. The application is acknom4edge'd with a 30 day waiting NAM, and allows the Board to issue a permit after 30 days, The application is denied. Pirin�t.colunIty name On behalff of the county, I acknowledge this application. S 11 1 'griature ofcounty official receiving application itle Date I (Optionall), TOWNSHIP-, On behalf of the township, I Date acknowledge that the organization is a,ppil�ying for exempted gambling activity Wthin township limits. [A township has, no statutoryi authority Title dd--e2� to approve or deny an application [Minnesota Statute 3419,166)) Print townsihip name Title Date 10 W Chief executive officer's, signature Im I. Financial report and recordkeeping required A financial report form and inIstr,uctions rill be sent with your permit, or use the online fill-in form available at www.gcb.state.mn.us. Within 30 days of the acIflivity date, complete and return the financial report formI to the Gambling Control Board., -PrintFoirmI- I Reset Foirm