Agenda - Council - 02/10/2009 - Laserfiche WebLink

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LG220 Application for Exempt Permit LOCALUNIJ OF GOVERNMENT ACKNOWLEDGMENT Page 2 of 2 6/07 If the gambling premises is within city limits, the city must sign. this application. Check CV) the action that the city is taking on >is application. ~The application is acknowledged with. no waiting period. _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60. days for a 1st class city). _The application is denied. Print city name C_:~'~ ~ ~ On behalf of the city, I acknowledge this application. . Signature of city personnelrece~.PPIiC. ation r:9~ . . \ Title r=~ ~~J~LL:U.s4- If the mbling premises is located in a township, both the cou ty and township must sign this application. Chec (V) the action thatthe county is taking on this app ~cation. _The appli~tion is acknowledged with no w . ng period. _The apPlicafton is acknowledged with a day waiting period, and a ows the Board to issue permit after 30 days. _The application i Print county name On behalf of the county, I a flj'Wtedge this application. Signature of county pers7 ,\iving application . // D~ l TOWNSHIP: 9ri behalfofthe township, / BC ow/edge that the organization is ppplying for exempted gambling tivity within the township limps. . [A township has no statutory auth rity to approve or deny anjlPplication [Minnesota Statute 349.213, s d. 2)] Print to.Wnship name . Title ,--.-- Si nature of township official acknowledging applica' n Date , ,__.__ CHle~\ E"'ECUJI\le;'QEF'I~ER'S;. 'Sl$NATU~e(t.:.~\.[.::t ;:;/;,~:>!:il":~' ,,%,'iY;;":~;'; ..)3;;;;'~:,:i,:.,;:'i;.;;~j;i;;:>'i{:;;";,'\, The information proliidedin this application is comp~and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and . . etf10 thSl Board within 30 days of the date of our gambling activity. Chiefexecutive officer's signature 1- DateJ~ / 2-t.? / :J-ocJ'J Complete an application for each gambing Financial report and record keeping . 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 Send application with: activity date, complete and retum the financial . a copy of your proof of nonprofit status, and report form to the Gambling Control Board. . $50 application fee for each event Make check payable to "State of Minnesota." To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy. This form will be made available in altemative format Q.e. large print, Braille) upon request The information requested on this form (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 qualitications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4076. 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. 'MIen 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 name and address which will remain public. Private data are available to: Board members. Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attomey General; Commissioners of Administration, Finance, and Revenue; Legislative Auditor, national and intemational gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically 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. -9-