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LG220 - Application for Exempt Permit Page2g� 1 <br />Organization Name <br />Local UnitcfGove <br />ment <br />Ifthe gambling premises iswithin city limits, the <br />city mustslgn this application. <br />On behalf of the city, I acknowledgethis application <br />Checkthe action that <br />the city is taking on this application. <br />❑The city approves the application with no <br />waiting period. <br />f the gambling premises is located in a township, both <br />he countyandtownship mustsignthis application. <br />3n behalf of the county, I acknowledgethis 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 city approves the application with a 30 day ❑ The county approves the applicationwith a 30 day <br />waiting period, and allows the Board to issue a waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class permit after 30 days. <br />city). <br />� The city denies the application. <br />Printnameaf city <br />(Signature of city personnel receiving application) <br />D�t�_. _ � <br />� The county denies the application. <br />Print name of county <br />[Signatureof county personnelreceiving application) <br />Tfl� <br />Date I I <br />TOWNSHIP: On behaif ofthe township, I acknowledgethat <br />the organization is applying for exempted gambling activity <br />within the township limits. [A township has no statutory <br />authorityto approve or deny an application (Minn. Stat. sec. <br />349213, subd.2).] <br />Print name of township <br />(Signature af township official acknowledging application) <br />Date 1 I <br />Chief ExecutiveOfficer's Signature <br />TT�e Inra�maR4an pro�idee ir� tt�� �p - r� i� �m��nd���a the bestof my knowledge. <br />Chief executive officer`s signature ' __ _ <br />r <br />r��,����� � � �: ���� �� � r f � f �. <br />Mail Application and Attachments <br />At least45 days priorto yourscheduledactivity date send: <br />• the completed application, <br />. acopyofyourproofofnonprofits�tr�s,and <br />. a$25 application fee (make check payableto "State of Minnesota"). <br />Application fees are not prorated, refundable, ortransferable. <br />Send to: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />Ifyour application has not <br />been acknowledged bythe <br />local unit of govemment or <br />has been denied, do not <br />send the application to the <br />Gambling Control Board. <br />