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LG22Q Appli�ation for Exempt Permit 1/13 Page 2 of 2 LQCAL UNIT QF Gt3VERNMENT ACKNQWLEDGMENT CITY APPROYAL COUNTY APPROVAL for a gambling premises far a gambling premises located within city limits lacated in a tawnship _The application is acknowledged with �o waiting period. The application is acknawledged with no waiting period, The application is acknowledged with a 30 day waiting The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days period, and allaws the Board ta issue a permit after 30 [60 days for a 1st class city]. days. The appliCatian is denied. Print city name Signature af city persannel Title The application is dsnied. Print county name 5ignature of counry personnel Date I Titie Rate TOWNSF[IP. If requir�tl by the couniy. On hehalf of the township, I acknowledge that the organizatian is applying far exempted gambling activity within the township limits. [A township has no statutory autharity to approve or deny lOCaI L1111t Of 9�V@CI1i]"�i�llf 11'1lISt S19f1 an application, per Minnesota Statutes 349.1b6.] Print township name Signature of tawnship officer Title CHIEF EXECUTIVE OFFICER`S SIGNATURE Date The information provided in this application is complete and accurake ta the best of my knowledge. I acknowledge that the financial re{�ort will be completed and returned to the Board within 30 days of the event date. (7rcas� r . ` �ie�xsc��e�r—'s signature Qate ��j I Print name �LA�a�,F�E� hE tt�v�-sr REQUIREMENTS Comptete a separate applicatlon for: • al! gambling conducted on two or more consecutive days, or • all gambling conducted on one day. Only ane appficatian is required if one or more raffle drewings are conducted on the same day Send application with: _ a copy of your proof of nonprofit sCatus, and _ app�ication fee (nan retundabfe). Make check payable to "State of Minnesota," � To: Gambling Contro! Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy notice: The Informatian requested on this form (and any attachments) wlll be used by the Gambling Control Board {Board) to determine your organlzation's qualificatfons to be lnvolved in lawfu! gamblfng activltles in Mlnnesota. Your organizatlon has the rlght Yo refuse ta supply the information; however, ff your organizatlon refuses to supply thls information, the Board may not be able to determine your orgaNzatlon's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the Information reguested, the Board wil! be ab{e to process the appllcatlon. Your organlzation`s name and address wlll be public tnformation when recefved by the Board. Financial report and recordkeeping required A financial report form and instruetions will be sent with your permit, or use the online fiil-in form avaffable at www.gch. sta te. mn, us. Within 30 days of the event date, complete and return the financial repart farm to the Gambling Control Board. Questions? Call the Licensing Section of the Gambling Control Board at651-539-1900. This form will be made available in alternative farmat {i.e. large print, Braille) upon request. All ather informatlon provided will be p�i- vate data abput your organizatlon until the Board Issues the permlt. When the Board issues the permit, all information provided wfll become publlc. Ef the Board does nat issue a perrnit, all information provided remafns prinate, wfth the exceptiDn af your organlzatlon`s name and address whfch witl remain pubfic. Prlvate data about your organization are ava{lahle to: Board mem- bers, Board staff whose work requires access to the Iniormation; Minnesota`s Department of Public Safety; A[tomey General; Commissioners of Adminlstratlon, Minnesota Management & Sudget, and Revenue; Legislative Audltor, national and Intematlonal gambling regulatory agencies; anyone pursuant to court order; other Indl- viduals and agencles speciflcally authorized by state or federai law to have access to the informatlon; Individuafs and agencies for which law or iegal order authoHzes a naw use or sharing af fnformation after this natice wa5 glven; and anyone with your written consent.