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LG220 Application for Exempt Permit Page 2 of 2 W1 11-0 CAL UNIT OF GOVERNMENT ACKNOWLEDGMEUT If the gambling premises is within city limits, If the gambling premises is located in a township,, a a city official must check the actfon that the city is county official must check the action that the county is taking on this application and sign the application. taking on this application and sign the application. A township official is not required ■ sign the application, -The application is acknowledged with no waiting period, :rhe application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a 1st class city), M 156TT, -me On behalf of the city, I acknowledge this application. Signature ofcity personme-1 receiving application The application is acknowledged with no waiting period. The aoplication is acknowledged with ■ 30 day waiting period, and allows the Board to issue a permit after 30 days. application is denied. I # r 1W On behalf of the county, I acknowledge this application, Signature of county personnel receiving application 7 Title Date it TitlE Date_. (Optional) TOWNSHIP: On behaff of the township, I acknowledge that the organization is applying for exempted gambling activfty within the township limits, [A township has no statutory authority to appmVeordenyan applicatlon (Minnesota iStatute 349.166)] Print township name Signature of township official acknowledging applicatfon Title Date iro I s, T; The Wbrmation provided in this application is complete and accurate to the best of my knowledge, I acknowledge that the financial report will be complpt d and returne to MeBoard within 30 days of the date of our gambling activity. a Chief executive officer's signature Date— Complete a separate application for each gambling event: • one day of gambling activity • two or more consecutive days of gambling activity • each day a raffle drawing is held !Lend application with: a copy of your proof of nonprofit status, and application fee for each event Make check payable to "State of Minnesota." To: Gambling Control Board 1711 West County Road B, Suite 300 Sout Roseville, MN 55113 1 ,juestions? .e% Call the Licensing Section of the Gamblin% .17ontrol Board at 651-639-4000. This fbrrn will be made available in altemative fbirmat (i.e. large print, Braille) upon request. Data privacy noti-ce: The information Your organization kv s name and Private data about your organization are available requested on this form (and any address will be public infbrmation to; Board members, Board staff whose work attachments) will be used by the Gambling when received by the Board. All requires access to the information; Minnesiota"s Control Board (Board) to determine your other information provided will be Department of Public Safety; Attomey General; organization's qualifications to be involved private data about your Commissioners of Administration, Minnesota in lawful gambling activities in Minnesota. organization until the Board Management & Budgetr and Revenue; Legislative Your organization has the right to refuse to Issues the permit. When the Auditor, national and international gamblfing supply the information, howeve r, if your Board Issues the perrrift,, all regulatory agencies* anyone pursuant to court organization refuses to supply this Information provided will become order; other individuals and agencies specifically information., the Board may not be able to public. If the Board does not authorized by state or federal law to have access determine your organization"s quacations issue a permit., all information to the information; individuals and agencies fbr and, as a consequence, may refuse to issue provided remains private, with the which law or legal order authorizes a new use or a pennit. If your organization supplIes the exception of your organization's sharing of inf6ii-mation after this notice was given; information requested, the Board will be name and address which will and anyone with your written consent. able to process your organizations remain public. application. Reset