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LG2Z0 Apptication for Exempt Permit 1/13 Fage 2 of 2 L�CAL UNIT K?F GOVERNMENT ACKNOW[.EDGMENT CITY APPROVAL COUN7Y ApPRGVAL for a gambfinq prerrtises for a gambling premises iocated within city [imits lacated in a townshi� The application is acknowledged with no waiting period. The application is acknowfedged with no waiting period. The applicatian is acknaw�edged with a 30 day waiting The appllcatton fs acknowfedged with a 3D cEay waiting periadr and allaws the 8oard to issue a permit after 30 days period, and allows the Board ta issue a permit after 30 [60 days for a 1st c(ass city], days, The applfcation is denied. The appfication is denied. Print city narne Print county name 5lgnature af city personnel Signat�re of county personnel Title Date Title Date 70WNSHIP. If required by the caunty. On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. [A township has no statutory authority to appra�e or deny Local unit of government must sign ' an aFPi�catia�, per Mlnnesoka Sfatutes 349.166.] Prink township name 5ignature of township officer Title Date CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this applicat€on Is complete and accurate to the best of r-ny knowledge. I aeknowledge that the financial report will be completed and returned to the Board within 30 days of the event date, Chief executive of�cer's signature Date Print name REQUIREMENTS Complete a separate applicatipn far: �inattciat report and recordkeeping required * a1[ gamb�ing conducted on two or more consecutive days, or A financial report form and instructions will be sent with yaur • all garnbling conducted on one day. permit, ar use the online fill-in form available at Only one appUcation is required if one or more raffle drawings '�ww.gcb,state.mn.us. are conducted on the same day Within 30 days oF the event date, camplete and ret�rn Send application with: the financial repart form to the Gambling Control Board. _ a capy af your proof of nonprofit status, and Questians3 _, application fee (non refundable}. Make check payable to Call the Licensing 5ection of the Gambling Control Board "State of Minnesata." at 651-539-19Q0. To: C'sar7'ibling Control 8oard This form will be made avai(able in alternative format (i.e. !arge print, Braiflej 1711 West County Road 8, Suite 304 South upon request. Raseville, MN 55113 Data privacy notice: The informatlon requested on this AII other [n�ormatian provided will be prl- General; Commissianers of AdminisCration, form {and any eitachments) wi(i be used by the Gambling vate data about your organizatior, until the Minnesota Management & Budget, aad Control Board (Board} to determine your organization's Board issues the permit. When the Board Revenue; LegislatWe Audltor, natlonal and quallflcations to be invo[ved in lawfu! gambling acti�itles tn issues the permit, alf information pro�ided Interriational gamhling regulatory agencies; Minnesota. Your arganization has the right to refuse to will become public. If the Board does noC anyone pursuant to court order; other indl- supply the inPonnation; however, if your organizatEan issue a permit, aii informatian provlded �iduals and agencies specificalty authorized refuses to supply this information, the Board may noE be remains pr[vate, with the exception Df your by stdte or Pederal law to hdve aCCe55 to able to determfne your orgaNzation's qualfFicatlons and, organization's name and address whfch wiH khe information; individuafs and agenCles as a consequence, may refuse to issue a permit. If ynur rematn publlc. Prl�ate data sbout your for which law or legal order authorizes a organizatlon supplies the fnformation requested, the Board organizatfon are avallable to: Baartl mem- new use or sharing of fnformaEian after this wiU be able to proeess the applicatton. Your organizatlon's bers, Board staff whose wark requlres notice was given; and anyone w!th your name and address wiEl be public information when recefved access to the ]nformation; Minnesota`s written consent. by the Boal'd. Department of Pubiic Safety; Attomey