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LG220 Application for Exempt P/e?rmgit <br />Organization Name ~C..(~~ fYl (_.r~~11 <br />Local Unit of Government Acknowledgment <br />If the gambling premises is within city limits, the <br />city must sign 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 />~-'Fhe city approves the application with no <br />waiting period. <br />The city approves the application with a 30 day <br />v/aiting 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 name of city C...~~~f C'f4' 1f~-~~ <br />(Signature of city personnel receiving application) <br />~^- r . <br />Date ~ /~/~ <br />Page 2 of 2 <br />If the gambling premises is located in a township, both <br />the county and township mustsign this application. <br />On 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 />(Signature of county personnel receiving application) <br />Title <br />Date / / <br />TOWNSHIP: On behalf of the township, I acknowledgethat <br />the organization is applying for exempted gambling activity <br />within the township limits. [Atownship has no statutory <br />authority to approve or deny an application <br />(Minnesota Statute 349.213, subd. 2).] <br />Print name of township <br />(Signature oftownship official acknowledging application) <br />Title <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 sig <br />Name(pleaseprint) Date I / <br />Mail Application .and Attachments <br />At least 45 days prior to your scheduled activity date send: <br />• the completed application, If your application has not <br />• a copy of your proof of nonprofit status, and been acknowledged by the <br />• a $50 application fee (make check payable to "State of Minnesota"). local unit of government or <br />Application fees are not prorated, refundable, or Transferable. has been denied, do not <br />Send to: Gambling Control Board send the application to the <br />1711 West County Road B, Suite 300 South Gambling Control Board. <br />Roseville, MN 55113 __ <br />-63- <br />