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r,� �'_�.r.�� re�iif' � GZZV wpp��caz�� a,. �..�... f,. . _- ----- LOCAL UNIT OF GOVERNNIENT A�KI�I�JWLED�GMENT' CITY APPROVAL for a gambling premises located within city lirnits The appllcation is acknowledged with no waiting period. �The application is acknowledged with a 30 day waiting �periad, and aHows the Board to issue a permit after 30 days [60 days for a ist class city]. The application is denied. Print city name Signature of �ity personnel Title � Local wni�-of government must s+�n ..; . 12/12 Page 2 of 2 COUNTY �►PPROVAL for a gambling premises focated in a township The application is acknowledged w+th no waiting period. 7he application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days. The application is den+ed. Print county name Signature of county personnel Title D ate TOWNSHIP• If required by the county. On behalf of Che townsh+p, I acknowledge that the organlzation {s apQlying for exempted gambling activity within the township limits. [A township has no statutory authority to approve or deny an appl9cation, per Minnesota Statutes 349.166.] Print township name Signature of township officer Title Date CHIEF EXECUTIVE OFF�CER'S.SIGNATURE The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be compieted and returned to Y e Board within 30 days f t ev��date. ` t d j13 / � G� �L Date a � Chief executive officer's signature Print name �r' S'rf-� �f�I �t �S�"� _ REQUIREMENT'S : Complete a separate applicatlon for: • al1 gambling conducted on two or more consecutive days, or • afl gambling conducted on one day. Qnly one application is required if one or more raffle drawings are conducted on the same day Send apptication with: a copy of Your proof of nonprofit status, and � application fee (non refundable). Make check payable to "State of Minnesota." To: Gambling Control Soard 1711 West County Road 8, Suite 300 5outh Roseville, MN 55113 Data privacy notice: Tfie informatian requested on this form (and any attachments) will be used hy the Gambli�g Control Board {Board) to determine your organization's qualificatlons to be involved in lawful gambling activities +n Minnesota. Your organization has the right to refuse to supply the information; however, if your organization refuses to supply this informatioo, the Board may not be able to determine your organization's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the information requested, the Board will be able to process the application. Your organization's name and address will be public information when received by the Board, Financlal report and recordkeeping required A financial report forrn and instructions will be sent v+rith your perrnit, or use the online fil!-in form available at www. g cb.state. m n. u s. Within 30 cfays of the event date, complete and return the financial report form to the Gambling Control Board. Qusstions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. This form witf be made available in alternati�e format (i.e. karge print, Braille) upon request. Afl other information provided will be pri- vate data about your organization until the Board Issues the permit. When the Board issues the permit, all information provided wiil become public. If the Board does nat issue a permft, a11 information provided remains privake, with the exception of your organization's name and address which wifl remain public. Arivate data about your organ¢ation are available to: 6oard mem- bers, Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Minnesota Maaagement & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other indi- viduals and agencies specifically authorixed by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent.