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L 2 0 Application for Exempt Permit
<br />PW 2 uf 2 sm71
<br />LOCAL UN 01F GOVERNPIENT ACKNOWLEDG14ENT
<br />if the gaml mg premiftmi; is in city iii
<br />V the garnblirtg premkos Is k=dad in a township, a
<br />a city vial must check, the action that the city Is
<br />county official must chei* the action teat the county rs
<br />taking on this application ands sign the application.
<br />taking on this application and sign the application.
<br />odw information provided Will be
<br />A township affidal is not requbre4l Uk $19ft the
<br />14
<br />applilca�tion,
<br />le application Is acknowledged with no waitirQi
<br />g1pplication is acknowledged with no waiting
<br />period.
<br />period.
<br />.The application is acknowledged with a 30 day
<br />.
<br />The appilcation Is acknowledged with a 30 day
<br />waiting period, end altows the Board to iss�ue a
<br />waiting perlod,. and allaws the ftod t ol issue a
<br />permit after 30 days.
<br />peirmit after 30, days (60 days fora city).
<br />.The a;*Iica1don Is denledbi
<br />Me apiplicaUon Is denied,
<br />Print county name
<br />a athu in*Muak and agwmtes, wedficaltf
<br />k*wn%Al on, the Board may rwt tw able t)D�
<br />Print city name - 4g-Lzae Z114
<br />On behaff of the county, I ack mow Aedge this apOlmdon.
<br />f
<br />Signaftre of coiunty pemonnel recielving application
<br />On behaff afthe dty,, I AcknowkC* this appikationd
<br />and, as a cora"ue"-,, may rekw to issue
<br />sign city pers"onwn,016receiving application
<br />which Jaw or legal order audwrim a new use, or
<br />a permL If your orgainizabons upplies the
<br />exceptJon of your organizatlants
<br />qVrjr* of Ifft,lTwom ~ ft tX*kg was 4jwcn;
<br />--Pa
<br />�J, 'ex, Dat* 1��Izel-h
<br />Titile- m
<br />(optional) TOWNSHIP: an behalf of the townsNp, I
<br />T
<br />% acknowledge dot Me, organ4wtbn is applyft obr, dxwnpted
<br />gambfing actfVgy W"in Me to, I* lhrft (A UMMI11p, has no
<br />datutm auftrity to approve or de av an isppllcAlan Minn tau
<br />Statute, 3'491.165))
<br />F"nit township name
<br />,Signatu�re of township oftial acknowledging application,
<br />-low" Pri - At fbirm anO,. have CEO..-Sjg.,n,-
<br />�CHIEF EXECUI TIVIE OFFICER'S SIGNATURE
<br />Information pmvkfed kt this appricaWn, & complete and ai=ratei to the best of my krwwAodge. I acknowledge
<br />that ffie finandal mplort wN be campAeted' 49#7d' ffie B in 30 dbys of the date gambling
<br />C'hlef e ecut" offi�cees signature Date
<br />........... -
<br />Complete a separate application for each gambling
<br />- -
<br />4vent: Financial report and recordkeeping
<br />9 one d�ay of garnbling activity
<br />re�q�uired
<br />40 two or more consecutive days of gambfing activity
<br />A finia�nc,ial repott, form and Instructions mill
<br />each day a raft drawing Is held
<br />be sent with your pennit, or use the offline:
<br />fill -in form avallablle at
<br />Send application with
<br />www.gcb.statx,mn.vs. WO�l�n 30, days of the
<br />a copy of your proolf'of'nonprofit status, and
<br />aMvity date, c�ompll ete and return the
<br />• appilication fee for eaich event
<br />financial report form to the Gambling
<br />Make check playable to "'Mate of Minnesota."
<br />Contral Board.
<br />questions?
<br />To-. Gambling Control Board
<br />Call the Licensing Section of the Gambling
<br />1711 West CountV Road 0 0 Su ft 300 South
<br />Control Board at 651-639-40,00.
<br />Roseville, MN 55113
<br />1 --7
<br />11 "IT114 I =A," 0 1 i ri *7 735r. Ft lamll, i nN-*7r7%,D]Ea:s1 R77o
<br />Data VWWaicy MWCW6 The information Your orgainization's' name and
<br />. i It"JI111-
<br />Atate date about )wr #UQCK"l I are av*k*le
<br />requested on this form (and any
<br />aeldnew will be public kftmatim
<br />to.- board members, Board stW whom, work
<br />aMadiments) *11 be used by the Gambling
<br />when n=Ived by the Swrd. All
<br />requires a tD, the InftTmtionr PlinnesaWs
<br />P
<br />Conbrd Board ('Ekmird), to determine Vour
<br />odw information provided Will be
<br />Depfirbrir Or tft, of Public S&W,", AMmey, Geranilf,
<br />orgmization's quarftftns to be involved
<br />private date about your
<br />C missiolnem of Administration, MinnesoU
<br />,4aM
<br />In, laiNful g ng a0vitles In Minnesota.
<br />organization until the Board
<br />Management & audget, , and Revenue; legbb#*v
<br />Your onjanhWan hm V* r%ft to ngUse to
<br />issues the pe"nit, When the
<br />Auditor, national and Interudonal gambling
<br />suipiply the InformbUon; ho rr If your
<br />Board Issues the permit, asill
<br />rajulstury apncles- anyone pursuant to court
<br />organization reNses to supply this
<br />h ft wrIBUon Provided WW b&:0M
<br />a athu in*Muak and agwmtes, wedficaltf
<br />k*wn%Al on, the Board may rwt tw able t)D�
<br />PU�WiC. If' the 13"rd does not
<br />"horized by, gum or ftdeval low to, have acom
<br />dcteffrdna your orqmiizabor0i qualYkations
<br />Issue a permilt; ail Irftrmation
<br />tD, the IrlibrIve6m; indm&ajs and &
<br />.Wcjes W
<br />and, as a cora"ue"-,, may rekw to issue
<br />provided remins private, u
<br />which Jaw or legal order audwrim a new use, or
<br />a permL If your orgainizabons upplies the
<br />exceptJon of your organizatlants
<br />qVrjr* of Ifft,lTwom ~ ft tX*kg was 4jwcn;
<br />Infbrmation requesbedl, the Board will be
<br />name and address which will
<br />and anyone w1th your wrften corwApt�.
<br />able to process, your organization's
<br />remain public.
<br />application.,
<br />ftsetform:
<br />
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