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lanjual <br />am <br />W <br />If the gaimbli�n�g premises 'is within city ts, <br />a city official mu�st check the action t,h�at the city [is <br />taking on this application and sign the application. <br />re of city official receiving application <br />Plagle 2 of 2 1111 <br />If the gambling premises, is located in a township, a <br />county official must check the action that the county is taking <br />on this application and sign the application. <br />A, township officiall is not requirled to sign the application. <br />The application is acknowledged with no, waiting period. <br />The application is acknowledged with a 30 day waiting <br />period, and allows the Board to i,ssu a permit after 30 <br />days., <br />The application is deniied. <br />al,rint county name <br />.7 <br />#Fn behaff of the county, I acknowledge this applicalUon. <br />Signature of county official receiving application <br />Title Date, <br />(Optional) TOWNSHIP: On behalf of the township, I <br />Title 16(fA Date cR I / 4el I'/ acknowledge that the organization is appilyiinig for, exempted garribling <br />activity vAthin township lim�its,. [A township has, no statutory authority <br />to approve or dleny, an application [Minnesota Statute 349.1166)], <br />Print, township, name <br />Signature of townsh�ip official acknowledging application <br />Title Date <br />-ER'Si-SIGNATTURE <br />'CHIEF EXEC UTIVE'OFFIC <br /># 0 0 1 .1 0 0 0 0 14�:MMJKV�1; <br />Chief executive officers siOature <br />1711 West County Road B, Su�ite 3,00 South <br />Roseville, MN 55113 <br />Date t k-f- / <br />inancial report and mcorldkeepingl required <br />A <br />financial report form and instructions will be sent with <br />your permit, or use the online fill-in form availlabll e at <br />.g l. state,. mln. us. Within 30 days of the activity date, <br />complete and return the financial report form to the <br />Gambling Control Board. <br />