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LG22Q Application for Exempt Permit 1/13 Page 2 of 2 LOCAL UNIT QF GOVERNMENT ACKNOWLEDGMENT CITY APPR�.IVAL CaUNTY APPROVAL for a gambling prerr�ises for a gambling premises located wtthin ciiy �imits Ioca#ed in a township _7he application is acknowEedged with na waiting period. The application is adcnowledged with na waitir�g period. The application is acknowledged wit9� a 30 day waiting The appfication is acknowleclged vrith a 30 day waiting period, anc! alfows the Board to issue a permit after 30 days period, and allows the Board to issue a permit after 30 [6Q days for a ist cEass city]. days. TThe applicatian is denied. Prini city name Signature of city �rsonnel Titie The appiication is denied. Print county name Signature of county persannel Date , Title Local unit of gover�ment must sign Date it�WNSHIP. If requfred by the co�nty. On behalf of the tawnship, T acknowEedge that the organization is applying for exernpted gambling activ'sty witihin the township limits. [A township has no statutory authority to apprave or deny an applicatinn, per M�nnesota Statutes 349.166.] Print township name Signature of township officer Tit[e Date CHIEF EXECUTIVE C�FFiCER'S SIGNATURE The information prnvided in this application is complete and accurate to the best of my knawledge. I acknowledge that the financ�al report will be completed and returned to�the Board„�itlpit� 30�qlays af the event date. Chiet executive officer's Print name REQIJIREMENi`� Complete a separate application for: • all gambiing canducted on twa ar rnore consecuti�e days, or • all gambting canducted on one day. Only ane application is required if ane or rnare raffie drawings are conducted on the same day Send applicatton with: _ a copy of your proaf of nonprofit status, and _ applica�io� fee (non reiurtdable). Make check payable to "State of Minnesota." To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy notice: The informatlon requested an this form (and any attachments) will be used by the Gambling Controf Board (Board) to determine your organizat�on's quali�3cations to be invol�ed in lawful gambfing activities in Minnesota. Your organlzation has the right to refuse to supply the information; however, if your organization refusss ta supply this information, the Baard may nat be able to determine your organizatfon's qualifications and, as a wnsequence, may refuse to issue a permit. If your organization supplies the information requested, the Board wiil be able to process tha application. Your organization's name and address will be pu6lic infurmatEOn when recei�ed by the Soard. Date r �O�'j'� Financial report and recordkeeping required A financial report form and instructians will be sent with your permit, or use the onkine fill-Rn iarm available aC www. g cb.state. m n. u s. Within 30 days of �he event date, compfete and return the Financial repnrt form to the Gambling Cantml Board. Questiona? Call the Licens€ng Sectian of the GBmbling Contra� Baard at651-539-1900. This form will be made availa6le in altemative format (i.e. large print, Bra71e} upon request. Alf other infarmation provided wiEl be pri- vate ddta about your organizatlon until the Board issues the permit. When the Board issues the permit, all information provided wtll become public. If the Board does not issue a permit, all infarmation provided remains private, with the exception of your organization's �ame and address which will remain putrlic. Private data about yaur organization are availabie to: Board mem- bers, Board staff whose work requires aaess to the ininrmation; Minnesota's Department of Public Safety; Attamey General; Commtss�oners of Administration, Minrresota Management & Budget, and Ravenue; LEgislative Auditflr, national and intemat"tonal gambling regulatory agencies; anyone pur5�ant to court order; other indi- viduals and agencfes specifitally authorized by state �r federal law to have access to the infartnation; individuals and agencies hor whiCh law or legal order �uthorizes a new use ar sharing of information aRer this notice was given; and anyone with yaur writken cansent.