Laserfiche WebLink
Page 2 of 2 <br />c.G220 -Application for Exempt Permit 3/01 <br />Organization Name�J��,¢Z—L.4I�:-� ,_�J'� ��''�C1`EC,1� ��'�-�.��• "I`' Ift`%'%/C1� �OC:,/��' <br />Local Unit of Government Acknowledqment <br />If the gambling premises is within city limits, the <br />citv must sinn this application. <br />On behalf of the city, I acknowledge this application <br />Check the action that <br />the city is taking on this application. <br />0 The city approves the application with no <br />waiting period. <br />�"The city approves the application with a 30 day <br />'waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city). <br />❑ The city denies the application. <br />Print n�q�e of city <br />(S <br />l� <br />receiVing application <br />Date � 1,� i 1���— <br />If the gambling premises is located In a township, both <br />the countv and townshlp must sinn this application. <br />�n behalf of the county, I acknowledge this application. <br />Check the action that <br />the county is taking on this application. <br />�The county approves the application with no <br />waiting period. <br />❑ The county approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days. <br />❑ The county denies the application. <br />Print name of county <br />($ignature of county personnel receiving application) <br />Date / / <br />TOWNSHIP: On behalf of the township, I acknowledge that <br />the organization is applying for exempted gambling activity <br />within the township limits. [A township has no statutory <br />authority to approve or deny an application (Minn. $tat. sec. <br />349.213, subd. 2),j <br />Print name of township <br />($ignature of township OffICi81 acknowledging application) <br />Title <br />Date_ / _ I _ <br />Chief Executive Officer's Signature <br />The information provided in this application is complete and accurate to the best of my knowledge. <br />Chief executive officer's signature <br />Name (please print) <br />Mail Application and Attachments <br />At least 45 days prior to your scheduled activity date send: <br />. the completed application, <br />. a copy of your proof of nonprofit status, and <br />. a$25 application fee (make check payable to "State of Minnesota'7. <br />Application fees are not prorated, refundable, or transferable. <br />Send to: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Rosevilie, MN 55113 <br />Date. / / <br />if your application has not <br />been acknowledged by the <br />local unit of government or <br />has been denied, do not <br />send the application to the <br />Gambling Control Board. <br />