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

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LG2217 Annlication for Exempt Permit Page 2 of 2 sio~- .LOCAL UNIT OF GOVERNMENT ACKNOW LEDGMENT If the gambling premises is within city limits, tf the gambling premises is located in a township, both the. city must sign this application. the county and township -must sign toes ,application: Check (~) the action that the city is taking on Check (~) the action tfrat the county is taking on application. this application. 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.. days (60 days fora 1st dass dty). The application is denied. _The application is denied. Print name ~. ~ ~ ~Y Print county name On behalf of the county, I admowledge this application. Signature of county personnel receiving application On behalf of the aty, !acknowledge this application. Signature of city personnel 'ving application ~~'~`'""~ Date / / Title Title ~ ~~,~~~-- Date °~' ` ~/ ~~ TOWNSHIP: On behalfofthe township, l ac{mow/edge thatfhe ' "--~'~ organization is applying focexempfed gambting activity within the 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 offidal acknowledging application Title Date / / CHIEF EXECUTIVE OFFICER'S SIGNATUR E The information provided in this application is complete and accurate. to the best of my knovvledge. l acknowledge that to t~e Bo ifhin 30 days of the date of our gambling activity. the financial report will be completed and reed I C~--t' Chiefexecutiveofficer'ssignature - Date ~ / ~ / ~~ Complete an application for each gambing activity: Financial report and recordkeeping • one day of gambling activity • two or more consecutive days of gambling activity required A financal report form and instructions will be • each day a raffle drawing is held seat with your permit Within 30 days of the activity date, complete and return the financal . 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 p.e. large print, Bra01e) upon request The information requested on this forth (and any attachments) wall be used try the Gambling Contrd Board (Board) to determine your quafdirah'ons to tie invohred in lawrul gambting activities in Minnesota You have the right to refuse to supply the inform><~+tion requested; however, if you refuse to supply this irforrration, the Board may not be able to determine your qualifications-and, as a corisequerrce, may refuse to issue you a permit ff you soppy the irrfornation requested, the Board wtil be able to process yore apptiptiori. Your name and and your organ¢afion's name and address vui~ be public infiornatiorr when received by the Board. All the other irtfornation you provide Mnll be private data trn>rl the Boars issues your parrot When the Board issues your permit, a6 of the arfortrration provided to the Board wtil become public. ff the Boars does not issue a permti, aq inforrrafiorr provided remains private, with the exception of your name acrd your orgari¢ation's name and address vutrodt vn'9 remain public. Private data an: available to: Board members, Board stafr whose worts requires access to ' the information; Minnesota's Department of Public Safety, Attorney General; Corrmissior~rs of Administration, Finance, and Revenue; LegislativeAud'rtor, national and irrtertratiorrat 9arnbfirxi regulatory agencies; anyone pursuant to cast order; other individuals and agerx5es that are speaficalfy autliotized by state or federal law to have access to the tirfomration; individuals and agences for which law or legal order auCarizes a new use or sharing of inforrr-ation after this Notice was given; and anyone with your consent -25-