Agenda - Council - 10/14/2008 - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of 2 9108 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT It the gambling premi6es i within City limits, If the gambling premises is located In a township, a a pity official must chuck (X) the ac#ion that the county official must check (X) the action that the county is taking on this application and sign the applica#ion. A city is taking on this application and sign the township official must also sign the application. application. application is acknowledged with no waiting period. ^_The application is acknowledged with no waiting period. ,The 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 days (60 days for 1 st class city), days. The application is denied. ,_„_ The application is denied. Print city name Print county name On behalf of the county, I acknowledge this application. On behalf of the city, I ackrfewledge this applicatiod7 Signature of county official receiving application Signature of city official receiving application Title Date I I TOWNSHIP: On behalf of the township, I acknowledge that ©"- the organization is applying for exempted gambling activity Title+"L�"�, Date// oi4 ; �9, -'- within township limits. (A township has no statutory.authority to approve or deny an application (Minnesota Statute 349.213. subd, 2)J Print township name Signature of township official acknowledging application Title Date �I I CHIEF EXECUTIVE OFFICER'S SIGNATURE rhe information provided in this application is c9rflplete and accurate to the best of my knowledge. i acknowledge that the financial report will be completed and retu he Board wit in 0 days of the date of our gambling activity. Date Chief executive officer's signat e Complete a separate application for each gambing activity: Financial report and recordkeeping • one day of gambling activity • two or more consecutive days of gambling activity required 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: a copy of your proof of nonprofit status, and report form to the Gambling Control Board. • $50 application fee for each event. Make questions? check payable to "State of Minnesota." Call the Licensing Section of the Gambling Control Board at 661-639-4076. To: Gambling Control Board 1711 West County Road B, Suite 300 South Print Form Reset Form Roseville, MN 55113 Data privacy. This form will be made available In alternative format (i.e. large print, Braille) upon request, The information requested on tbhn (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit.- If you supply -the information requested, _20_ the Board will be able to process your application. Your name and and your organization's name and address will be public information when received by the Board. All the other information you provide will be private data until the Board Issues your permit. When the Board issues your permit, all of the information provided to the Board will become public. If the Board does not issue a permit, all information provided remains private, with the exception of your name and your organization's riddartroad public, availableo: B members, Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Finance, and Revenue; Legislative Auditor, national and International gambling regulatory agencies; anyone pursuant to court order, other Individuals and 09lni especifically authorized by state or federal law to have access to the information; Individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.