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LG220 Appl�cation for Exempt Permit <br />I�OCAL UNIT OF GOVERNMENT ACKNOWL.EDGMENT <br />If the gambiing prerriises is within ciEy lirriits, <br />a city afficial must check the action that the c€iy is <br />taking an this application and sign the application <br />+�The applicafion is acknowledged wifh no waiting periocF. <br />�The applicafion is acknowledged with a 3D day waiting <br />period, and allows the 6oard to issue a permit after 30 <br />days {60 days for a 1 st class city). <br />��he application. is deni:ed. <br />Print city name C,tT�-� �� �D�11� [�,�.�,. <br />On behalf of the city, ! acknowledge this application. <br />Page 2 of 2 7109 <br />If the gambling prerr3ises is located in a township, a <br />county official musf check the action thai the county is taking <br />on this application and sign the application. <br />A township official is not required to sign the applica�ion. <br />The app3ication is acknowledged with no waiting period. <br />_The appfication is acknowlettged with a 30 day waiting <br />period, and aElows the Board tp issue a permit after 30 <br />days. <br />_The ap{�lication is denied. <br />Prini counfy name <br />On behalf of the county, I acknowledge this applicafion. <br />Signature of county official receiving application <br />Signature of city aff.icial ceiving ap lication _ <br />Title <br />��J r' {Optional) 70WN5HIP: On behalf of the township, I <br />Tltle %��ifr�.� ��` � �3fe �� 1�!� acknowledge tha! the organization is appfying for exempted gambling <br />activity within township limits. [A township has no statuio:ry authority <br />to approve or deny an appiication [Minnesota Statute 349.186}] <br />Print towaship name <br />5ignature of townsi�ip p��ial acKnowledging application <br />Title Date / <br />CH[EF EXECUTIVE OFFICER'S SiGNATURE <br />The informatron provided in this applrcation is complete and accurate ta fhe best of my knowledge. ! acknawledge that fhe <br />financia! report will be completed and ref ed fo fhe Board wiihin 30 ays of th date oiourgambling actrvity. <br />� <br />Chie# executi�e officer's signafure ._�� ���.Q � Date �� -2 -� <br />Compleie a separate application far each gambing activity: <br />- one day of gamb€ing activity, <br />- fwo or more consecutive days of gambling acti�iiy, <br />� eaci� day a raffle drawing is held <br />Send application with: <br />- a copy af yaur praof af nonprofii status, and <br />- application fee for each event. <br />Make check payable to "State of Minnesota." <br />70: Gambling Gontro! Board <br />1711 WesE Caunty Road B, SuiFe 300 South <br />Roseville, MN 55113 <br />�ata privacy. ihis form will be made a�ailable <br />in alternati�e farmat (i.e. large print, Braille) <br />�pon requesL The information requested on <br />this f.orm (and any attachmenEs) will be used by <br />the Gambling. Controf Board (Board} to <br />de€ermine yaur qualificaiions tp be involved in <br />lawiul gambling activiiies in Minnasota. You <br />have t�e rigM to refuse lo supply the <br />informafion requested; however, if you refuse So <br />supply this information, the Board may noi be <br />at�le to determine your qualifications and, as a <br />consequence, may refuse Lo issue you a permit. <br />If you supply the information reguested, <br />Financial Fepol't and recordkeeping required <br />A financial report form and instructions will be sent wifh <br />your permit, or use the online fill.-in form a�ailable at <br />www.gebsYate.mn.us. Within 30 c�ays of the activify date, <br />complefe and refum the financial repor# forrn to the <br />Gambling Contrpl Board. <br />Questiar�s? <br />Cal) ihe Licensing 5ectian of tha Gambling Conirol <br />Board at 651-639-4076. <br />Fill-in & Print Form Reset Farm <br />tha Board will be able to pracess your <br />applicaiion. Your name and and your <br />organization's name and address will be public <br />information when received by the Board. All <br />ihe other informafion you provide will be privaie <br />data until the Board issues your permit, When <br />the Board i5sues your permit, all o( the <br />information provided ta !he 6oard will 6ecome <br />public, lf the Board does not issue a parmit, all <br />iniormation provided remains private, with the <br />exception af your name and your organization's <br />Rame and address which will remain public. <br />private data are available to: Board memhers, <br />Board staff whose work requires access to the <br />information; Minnesota's Departrnent of Pu61ic <br />Safety, Attorney General; Commissioners of <br />Adminis#ration, Finance, and Revenue; <br />Legislafive AudiYor, national and internaiional <br />gamh€ing regutatory agencies; anyane pursuant <br />to courtorder; other individuals and agencies <br />that are specifcally authorized by state or <br />federal law to have access to the information; <br />individuals and agencies for which law or legal <br />order aufhorizes a new use or sharing of <br />information after this Natice was given; and <br />anyone with yaur cansent. <br />