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LG220 Application for Exempt Permit <br />Organization �ne Roseville Central Park Foundation <br />Local unit of Government Acknowledament <br />Page 2 of 2 <br />3101 <br />If the gambling premises Is within city limits, the I the garnbling pre�nises Is located in a township, both <br />cfty m u st s i g n this �pptic.etion. he couM�► and tawnahlp must stgn this app{Icatbn. <br />0� behelf of the city, I acknowledge this application, )11 behalf of the county, I acknowledge this application. <br />Check the action that <br />the city is taking on this application. <br />�The city approves the application with no <br />waiting period. <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 />n The c'Ry approves the application with a 30 day � The county approves the application with a 30 day <br />�,-� waiting period, and allows the Board to issue a W�9 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 />Print name of city <br />(Signature ofcity personnel receiving application) <br />��i��l <br />❑ The county denies the application. <br />Prr'vit name of county <br />Signatureofcounty personnel receiving application) <br />ri <br />�a�e_� �_ <br />TOWNSHIP; On behalf of the township, I acknowledge that <br />he organization is applying for exempted gambling activity <br />within the tpwrlship limits. [A township has no statutory <br />authority to approve or deny an application (Minn. Stat. sec. <br />349.213. subd. 2).j <br />Print name of township <br />(Signature of townshipofficial acknowledging application) <br />Date I I <br />Chief Executive Officer's Signature <br />�he information provided in this application is complete and acc�te to tt�� best of my knowledge. <br />�hj@f�XBCtl�jy@ officer's s <br />Vame (piease <br />� <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"). <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 />Roseville. MN 55113 <br />Date � I � I� <br />lf your application has not <br />been acknowledged bythe <br />bC81 unit of government or <br />has been denied, do not <br />send the application to the <br />Gambling Control Board. <br />