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<br />LG220 Application for Exempt Permit
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<br />Flage ;2 ot:2
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<br />7/09
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<br />LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT
<br />11 the gambling premises Is within city limits. If the gambling premises I. located in a township, II
<br />I city official ml.lst check the action that the city i$ county official mUlt check the action lhat the cQl.lnty II taking
<br />taking on this application and 3ign the application. on this appllQatlon and sign the application.
<br /> A township otflclal 'S not r.qulr.d to "gn the application.
<br />_The application is acknowledged with no waiting pertod. _The application Is acknowledged with no waiting period,
<br />_The application is acknowledged with a 30 day waiting _The application Is acknowledged with a 30 d.y waiting
<br />period, and allows the Board to issue a permit after 30 period, and allows the Board to luue a permit after 30
<br />days (60 days tor a 1st clIJss city). days,
<br />_The application Is denied. _The application Is denied,
<br />Print city name R A""\S t."" ) /J1 AJ Print county name
<br />On be/,alf of the city, I acknowledge this applicatfon, On behalf ofthe county, I acknowledge this application.
<br />Signature of county otTic!sl receiving application
<br />Signature of city official receiving application
<br />cf)- ~. ~
<br />-q~ . Title Oate_I_I_
<br />Title r-: '........... ~~ ~: ec:.roate..L/_~.jl:9- (Optional) TOWNSHIP: On behalf ot the township, I
<br />acknowledge that the organization Is applying for Elxempted gambling
<br />activity within township /lmila, fA towl1.hlp has no statutory authority
<br /> to approve or deny an applleatlon (Mlnl1esota Statute 349, HiS)]
<br /> Print township na",.
<br /> Signature of townShip official aeknowledging application
<br /> Tide 0.t8_1_1_
<br />CHIEF EXECUTIVE OFFICER'S SIGNATURE
<br />Thtt information provided in this application Is campleta and accurate to the best of my knowledge. I acknowledge that the
<br />((nanclll report will be completeQ and "tumed to the Board within 30 days of the dale of our gambling IIctivity.
<br />Chief executive officer's signature~ ~ ~11~{J.t' fL. - Date I{S( 10
<br />Complete a separate application for each gambing activity: Financial report and recordkeeplng required
<br />. one day of gambling activity. A financial report form and Instructions will be sent with
<br />- two or more consecutive days of gambling activity, your permit, or use the online fill-in form available at
<br />. each day a rame drawing is held www,gcb.state.mn.us. Within 30 days of the activity date,
<br />Send application with: complete and return the financial report form to the
<br />. . copy of your proof of nonprotlt status, and Gambling c:ontrol Board.
<br />. application fee for each event. Qu..tlo"s?
<br />Make check payable to "Stete of Minnesota," Call the L.icenslng Section of the Gambling Control
<br />To: Gambling Control Board Board at 651-839-4076,
<br />1711 West County Road 8, Suite 300 South I Print Form I I Reset Form I
<br />Rel.vllla, MN 55113
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<br />Oata prlvaoy. Till. form will be mad. Ivallable till' !laird willl:le abl, to "roe.." your
<br />In Ilt.rn.tlv. torm.t (1". larg. print, Brslll.) applh:allon, Your nlm. and .nd your
<br />u!)on requllt, Th. in'ormation requllted an organiZltlOt1'. name .nd ad dr... will b. !)ubUo
<br />l/li. torm (and any IIt.chmena) will be u..d by Informatlon when rec.,ved by tll. Sa.rd. All
<br />the Gembllng Control Baird (Board) to thl other Intarmatlan you ",avlde wllIl:le priVate
<br />determine your qUIllftc.donalo b. Involved In dlta until tile Baerd l..u.. your permit. When
<br />lawful gambling actlvitl.. In Mlnn..ota, You the Board illu.. your ".rmlt, allot the
<br />have the right to refuBlto aupply the Intarmadan prOVided to the Board will become
<br />information "ClulStad: however, it you ,efull to pUblie, It the Board doal not Illue I permit, all
<br />supply thilllntormallon, ti,e Soard may not ba intormadon providad ramain. privat., with the
<br />able to determine your Clualltlcadons and, Ie a excepllon at your nama and your organizadon',
<br />connquence, may rafuae to luua you a permit. name and addreas which will ramein public.
<br />It you supply the intormation requested, Privata data araavallabla to: Board members,
<br />
<br />aoera staff wholl work ,.qulr.. aecII. to tns
<br />Informatton: MI""..ota'. O,partment Qt Flubllc
<br />Satety: Attorney General; Comml..ionl" at
<br />Adminlltratlon, F1nanQI, and Rlvenue;
<br />l.eglalallve Auditor, nldonal and International
<br />gambling regUlatory agenci.s; Inyone purauant
<br />to court order; other indlvlduala and ag.nelll
<br />that are Ipeeltlcllly authorized by atllte or
<br />tederallaw to heve aeeesa to the Inform ell on;
<br />Indlviduall and agenci" for which law or legal
<br />ordar authorizes I new UIB or Ihering ot
<br />information after this Notlca was given; and
<br />any~ne with your conlent.
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