Agenda - Council - 02/12/2008 - Laserfiche WebLink

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• • 1 nn,)n Annlirratinn Mr FXP_mnt•Permit Page 2 of 2 6107 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the gambling premises is located in a township, both the city must sign this application. the county and township must sign this application. Check (�V) the action that the city is taking on Check (4) the action that the county is taking on this application. this application. �— The application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. to court order, other individuals and agencies that are specifically authorized by state or The application is acknowledged with a 30 day waiting _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 p days. - days (60 days for a 1st class city). _The application is denied. _The application is denied. anyone with your consent. Print city name C� �� Print county name On behalf of the county, 1 acknowledge this application. -25- Signature of county personnel receiving application On behalf of the city, t acknowledge this application. Signature of city personnel r ceiving application Title Date OWQI �/ � / I that the Title rDate TOWNSHIP: On behalf of the township, acknowledge organization is applying for exempted gambling activity within the township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349.213, subd. 2)] Print township name Signature of township official acknowledging application Title Date CHIEF EXECUTIVE OFFICER'S SI URE The information provided in this application s co)#4 and accurate to the best of my knowledge. / acknowledge that 11 Board 30 days of the date of our gambling activity. the financial report will be completed n u to a within Chief executive officers signature DateJC, J&—/—i /a'a Complete an application for each gambriri-glactivity-1 Financial report and recordkeeping • one day of gambling activity required • two or more consecutive days of gambling activity A financial report form and instructions will be • each day a raffle drawing is held sent with your permit. Within 30 days of the activity date, complete and return the financial Send application with: report form to the Gambling Control Board. • a copy of your proof of nonprofit status, and • $50 application fee for each event. Questions? Make check payable to "State of Minnesota." Call the Licensing Section of the Gambling Control Board at 651-639-4076. To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy. This form will be made available in alternative format (.e. large print, Braille) upon the Board will be able to process your application. Your. name and and your Board staff whose worK requires access io the information; Minnesota's Department of request. The information requested on this form (and any attachments) will be used by the organization's name and address will be public information when received by the Board. All Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; Gambling Control Board (Board) to determine your qualifications to be involved in lawful the other information you provide will be private data until the Board issues your permit. When Legislative Auditor, national and intemational gambling regulatory agencies; anyone pursuant gambling activities in Minnesota. You have the the Board issues your permit, all of the information to the Board will become to court order, other individuals and agencies that are specifically authorized by state or right to refuse to supply the information requested; however, if you refuse to supply to provided public. If the Board does not issue a permit, all information remains private, with the federal law to have access to the information; individuals and agencies for which law or legal this information, the Board may not be able determine your qualifications and, as a provided exception of your name and your organization's order authorizes a new use or sharing of information after this Notice was given; and consequence, may refuse to issue you a . permit. If you supply the information requested, name and address which will remain public. Private data are available to: Board members, anyone with your consent. -25-