Agenda - Council - 02/24/2009 - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of 2 s/os LOCAL UNIT OF GOVERNMENT ACKNOW LEDGMENT - If the gambling .premises is within city limits; If the, gambling premises is located in a township, a - a city official must check (X) the action that the county official must check (X) the action thatthe county .city is taking on this application and sign the is taking on this application and s%gn the application.. A application. township ofFcial must also sign the application. ~he application is acknowledged with no waiting period. The application is acknowledged with no waiting period. 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 fora 1st class city). days. The application is denied. The application is denied. Print city name ~`~~ c~' ~ Print county name On behalf of the county, I acknowledge this application. . On behalf of the city, 1 ackno ledge this application. Signature of county official receiving application ti li i on ca Signature of city official rece vin app ^ ~.) `~,` ~ ~ ~~~~~~"'---"' Title Date / / TOWNSHIP: On behalf of the township, I acknowledge that ~LS~ Date ~ /~/ ~ Title ~ ~ ~ the organization is applying for exempted gambling activity . within township limits. [A township has no statutory authority to C~-~: cSLf"~ 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 SIGNATURE The information provided in this application is complete and accurate to the best of my knowledge. 1 acknowledge That the da of fhe date of ur gambling activity. trnancial report will be completed and retu d to the Board r 'n 30 /~ G Chief executive officer's signature ~ ate ('a. ~ ~'( a~ I Complete a separate application for each gatnbing activity: 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: a copy of your proof of nonprofit status, report form to the Gambling Control Board. and' $50 application fee foreach event-Make check payable to " Questions? State of Minnesota." Call the Licensing Section of the Gambling To: Gamblin Control Board Control Board at 651-639-4076. g 1711 West County Road B, Suite 300 South R vill MN 55113 Print Form Reset Form ose e, Data privacy. This forth will be made available 4he Board will be able to process your Board staff whose work requires access to the in alternative format (i.e. large print, Braille) application. Your name and and your information; Minnesota's Department of Public upon request The information requested on organization's name and address will be public Safety; Attorney General; Commissioners of this form (and any attachments) wilt be used by information when received by the Board. All Administration, Finance, and Revenue; the Gambling. Control Board (Board) to the other information you provide will be private Legislative Auditor, national and international determine your qualifications to be involved in data until the Board issues your permit When gambling regulatory agencies; anyone pursuant lawful gambling activities in Minnesota. You the Board issues your permit, all of the to court order, other individuals and agences have the right to refuse to supply the information provided to the Board will become that are speafically authorized by state or information requested; however, if you refuse to Public. ff the Board does not issue a permit, all federal law to have access to the information; supply this information, the Board may not be information provided remains private, with the ' individuals and agencies for which law or legal able to determine your qualifications and, as a s exception of your name and your organization order authorizes a new use or sharing of consequence may refuse to issue you a permit name and address which will remain public information after this Notice was given; and , If you supply the information requested, Private data are available to: Board members, anyone with your consent -21-