Agenda - Council - 07/14/2009 - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of 2 9/08 .' .._ ",. . ".d. _ .'" ."m....._...__........_,.. '._'. ..__.,.... _.' .." .._.", ," . LOCAC'UNIT .OFGOVERNMENT'ACKN'OWGEDGlVIENT Ifthe gambling premises is within citY limits, a city official must check (X) the action that the city is taking on this application and sign the 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 1 st class city). _The application is denied. Print city name c...~ ~~ c:::>~ .e.c:..-~ On behalf of the city, I acknoWledge this appliCBiiOOO Signature of city official r. &j~ TitleF'. .~<..t-. Q-{-":, ~ Date~~~1 a, l~CH!E!= EXECUTI\IE O;:FIC=R'S If the gambling premises is located in a township, a county official must check (X) the action that the county is taking on this application and sign the application. A township official is not required to sign the application (unless required by the county). _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. _The application is denied. Print county name On behalf of the county, I acknowledge this application. Signature of county official receiving application Title Date-f-f_ (Optional) TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349.166)] Print township name Signature of township official acknowledging application Title Date-l-l_ The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned to the Board within 30 days of the date of our gambling activity. Chief executive officer's signature Complete a separate application for each gambing activity: - one day of gambling activity, - two or more consecutive days of gambling activity, - each day a raffle drawing is held Send application with: a copy of your proof of nonprofit status, and $50 application fee for each event. Make check payable to "State of Minnesota." To: (>~..t:lin~.: ':;~n!rJI' :Ae] 1711 '.Ve:t County Road F', SlIite 300 South Rosoville, MrJ 55113 Date Financial report and recordkeeping required A financial report form and instructions will be sent with your permit. Within 30 days of the activity date, complete and return the financial report form to the Gambling Control Board. Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4076. I'Fill;iIGiMl Data privacy. This form will be made available in alterr1-?:: "; fc~~n(Jt (i.e. 18r~',: prin:, f!-raiile) upon r(;~u .-..-t. "I nc iriforrn<..:i.lur) rec;:.J(;5tcd on this form \"nd any iJ:tashrnonts) w:i: be used by the Gambling Contr('1 "Oim:' (8oard) to determine your qu~li'ications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the informcl('o,. requested; however, if you refuse to sup~I}/: <:; inforn:c.;;i-...;n, tnc f;,oard Ilid! fl0t Ul2; able :c c;,:~rminc YOL,r qualifications and, as a cons,..:{. : ":.e, 01<' If..Jusc :0 issue: yell a r:;r;r'~ljt. If you '0'.",)1/ thr. ")'''''':' '...., :8";.:J, the Board will be able to process your application. Your name and and your organiza,ion'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 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; Attorney General; Commissioners of Administration, Finance, and Revenue; Legislative Auditor, national and international 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.