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<br /> <br />LG220 Application for Exempt p~r~ <br /> <br />Organization Name [" W Tn (" ..)- S <br /> <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises is within city limits, the <br />city must sign this application. <br /> <br />On behalf of the city. I acknowledge this application. <br /> <br />Check the action that <br />the city is taking on this application. <br /> <br />The city approves the application with no <br />waiting period. <br /> <br />O The city approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city). <br /> <br />o The city denies the application. <br /> <br /> <br />PrintJ5eofci~ C~ ~ <br /> <br />(Signature of city personnel receiving application) <br />litle ~~ ~iL ~ ~ <br /> <br />Date 7 /~!:!1: <br /> <br />Chief Executive Officer's Signature <br />The information provided in this application is co <br /> <br />NoW/I'[ {~/lAam .W.tf <br /> <br />Page 2 of 2 <br />12/03. <br /> <br />If the gambling premises is located in a township, both <br />the county and township must sjgn this application. <br /> <br />On behalf of the county, I acknowledge this application. <br /> <br />Check the action that <br />the county is taking on this application. <br /> <br />o The county approves the application with no <br />waiting period. <br /> <br />o The county approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days. <br /> <br />o The county denies the application. <br /> <br />Print name of county <br /> <br />(Signature of county personnel receiving application) <br />TItle <br />Date---1---1_ <br /> <br />TOWNSHIP: On behalf of the township, I acknowledge that <br />the organization is applying for exempted gambling activity <br />within the township limits. (A township has no statutory <br />authority to approve or deny an application <br />(Minnesota Statute 349.213, subd. 2).] <br /> <br />Print name of township <br /> <br />(Signature oftownship official acknowledging application) <br />TItle <br />Date <br /> <br />est of my knowledge. <br /> <br />Chief executive officer's signature <br /> <br />Name (please print) 'T{ M r c<!-he.. <br /> <br />Mail Application and Attachments <br /> <br />At least 45 days prior to your scheduled activity date send: <br />. the completed application, <br />. a copy of your proof of nonprofit status, and <br />. a $50 application fee (make check payable to "State of Minnesota"). <br />Application fees are not prorated, refundable, or transferable. <br /> <br />Send to: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br /> <br />Date (p I~ <br /> <br />If your application has not <br />been acknowledged by the <br />local unit of government or <br />has been denied, do not <br />send the application to the <br />Gambling Control Board. <br />