|
LG22q Applic:ation far Exempt Permit �r�.s v�nEzorz
<br />LOCAL IJNIT OF GOVERNMENT ACKNpWLEDGMENT
<br />^ i CITY^APPROVAL � COUNTY APPROVAL
<br />for a gambling premises for a gamUling premises
<br />located within cfty limits located in a township
<br />_fite applka8on Is acknowledged Wlth no v✓altin� perlod, _I'he application is acknowied[Jed with no waltinq perlod.
<br />_The flpplication is ar.knowiedgeA with a 30 dciy walting The apptication is acknoWledyed with a 30 day waltlnc�
<br />periocl, ancl allaws thn 8nard to Issuc. a pprnilt �aPkor 30 A�ye pniind� dltKl AIIDWS Cfl(� EiOdfA f0 ISSII@ B n@f�hlC 8('P@I' 3U
<br />[60 Aays for a 1st class city]. days.
<br />_Tbe applicatlon is denied. The appllcaUon l.s denied.
<br />Prinf dty narne _ Print counky iiame .
<br />Sipnature oP dty personnel Siynature oPcounty personnel �
<br />Title Date Tikle D'aYe
<br />FOWNS1i.LP. I.f required dy the c�unty.
<br />On behalf of the fowns-hiV, 1 acknowlecic�e that the orgaNzatiai
<br />Is applying f�r exeirrpted gamblin4! �c8vlty w3fhin the township
<br />Illnihs.
<br />��_ ._ :� . = GA tnrvnship h�s i�n yCaCUkniy 7uthority to al�Pr�ve pr cleiry
<br />� Local unit of gover,n�nent mu�t segn = an atapllc�qon, pee Mirviesnta S¢aluf¢s JA�J,IGG.]
<br />— — —...� — -- Frink Cnwnship name ___.____' _...__'_� _--
<br />Sic�nature of townshi�a nfficer .....................__...._.._...........___.._.._........_..._......,...._.
<br />Tltle Date
<br />._._..____ .—__...._�__.._... ._......_.... __._.__...__, .... _._...,._.. . ,_ . . ._._..__.__.___ ......... . , .,.__�_ ......... . ........_
<br />CHIEF EXECUTIVE OFPICER`5 SIGNATURE
<br />The Informatlon provicied In this ipplicatlon ls compleke and ar.curate ta the best af my knowledge. I� atknowleds7e khat the finanr,lal
<br />report will be cottiple[ed and reeurned to [I Board wi[h�n 9 �ty� ot the event da[e, �
<br />Chlef exeaitive ofPicer's signatum .......... ..........."...'........ ..._...._�, � . O��te_�� ! 9��
<br />..�.......-'----.........,_.. -----
<br />I�rink nama ��y�� �
<br />REQUIREMEN7S
<br />Campletc a sepante application fnr. Financial repar[ and recordkcepin� required
<br />•�II c�ambliny canducted on [wo pr morc consecutive rJays, nr /+ financlal reErart fnrm and Instructlons wlll bo sent with your
<br />• all gambtlnq conducted on ono day, p�i'i�it, or uso hbe ot�line fill-in fiv�tn avallabip al'
<br />Only one applir.adon is requlred IF one or ntoi'e nfPle tlrawinqs www.�cbstate.mn.us.
<br />tare cooclucCecl on thR samc day Within 30 days of the event cl�Ce, winplete and return
<br />5e.i3d epplication +viffr Che fina�7clal rePOrC Parm ta Chn Gambling C,onCrol 13ot�rcl.
<br />_ a copy of yom� proof of nonprofit status, aod (�ucstlous7
<br />..,_ ap��lir,aCion fee (nvn refi.indable). M�ke check payabte Ca Call Che 4lcensing S�tction of Yhe Gamblin� Caatrol �3oard
<br />"State of Minnrsote." ;�t G51-539-1.900,
<br />To: G�mb�InflGOntrolF7oafd 7hlsformwilibenudeavalla6lefnalternaNveformatp.e.largeprmt,eraille)
<br />17Z3 West County Rn�sd B, Su9ce 300 SouCh up4n requer�:
<br />Ro,r.ville:, MN 557.1.;.1
<br />Dnta prWacy noCicc: "tl�e Informatbn reque5ted o� tnls nil othcr information provltletl wlll be pri- Generai; Cpmmissioner, of Adminf5tiation,
<br />furm (anA any attachmetiCS) will Ue used by the Gan��blmp vate dACa akaat your �r9anlzat�on urttll the Mfnnesota Managemen[ & Bud�eC, and
<br />ConCP�l 130ard (BOdrd) Go detel'mine ytlur' Uryetli2At7dn's FSptird IS&ues t'I�z t�ermlC. Witen the BnarA Revenue; Lerjislativo Auditor, naCionui encl
<br />yualiflGatlot5s tn f�N involved ii5 lawtul gan1171in4 aCCIVICie9 tr� IssueB cbe perm�C, all informatlon providetl internatlonal gamUling repulaCury age.nGlea;
<br />Minnesota. Your nrgaNZatlnn has the ri9ht to refu,e [o wlll i�emme p�iblir., if the Baar�l does n�[ anyqne pur,=,uant [o cnurk orAer; othr.r fndl-
<br />suPPly the informanon; hnwever, If your orga�ization Issue a permit, all inFpima[ion Provided viduals ind agenciec spedFlcally au[horized
<br />refuses ka supply [his InFOrmation, the Board may not M rematns prvvatc, wlth the exr.eptbn oP your by state ar tederal law m have access to
<br />alile to defermine yau� organlzacfon'x qualiflr���o��s enr,t, oryanizatlon's name ancl asldress whldi will the InfurmaUon; Indivlduels and Agencies
<br />as a corue�uence, may refuse to Issue a pen'NC If your rernaln public. Pi iv»fe data akrout your for which law or leqal orAer authvil��es a
<br />orpantr.afl�n suPV���y Gie informaUOn requesf:ed, the Rn�rA orqanization ere available to: t3oerd mern- netH use or shartn9 of intormatlon aFter thi,
<br />wlll bt. able to proce&s thcx �pplfcakinn. vaur m-ganuatinn's bers, eoard staff whose tvork requUe=. noUce, was gwen; anA anyone with ynur
<br />nAme anA adAress will be pu6GC Infnrmation �5�hen received a¢ess to the information; Pilnnesnta's wntten cansent.
<br />Uy the eoard. Oepartmen[ of Public �atety; Fl[tnrney
<br />
|