Agenda - Council - 01/12/2010 - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of2 7JOS LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling pl'1lmllts Is within city limits, If the gambling premises is located In a township, a a city offlclal must check the actton that the city Is county official must check the ac:tion that the county Is taking taking on this application and sign the application, on thi, application and sign the application, . A township official 'I not required to "gn the application. 2s::Th. application i. acknowledged with no wllitlng period, _The IIlPplicatlon ia acknowledged with a 30 day waiting period, and allows the Bo.rd to ISlue a permit an.r 30 days (60 days for a 1st class city), _The application I, denied. Print city name On behalf of the city, I BClenO Signature ~ty =ecei2.:.'ication Title "r' 1'lu.N,A-c:s:+; u.ome--1I---=U~ _Th. applleatlon ia acknowledged with no waittng period. _The IiIPplleatlon is acknowledged with a 30 day waiting period, and allows the Board to inue 8 permit after 30 days. _The applleatlon Is denied, Print county name On beh81f of the county, I acknowledge this ,pp/lc8tlon, Signature of county official rec:elving application Title Date----!---1_ (Optional) TOWNSHIP: On behalf of the township, I acknowledge that the organization ia applying for axempted gambling actllllty within township limits. [A township hIS no statutory authority to approve or deny an application [Minnesota Statute 3~9.186)) Print township name Signature of township offlcial acknowledging application Title Oate _1---1_ CHIEF EXECUTIVE OFFICER'S SIGNATURE The inform.tlon provided in thl. application II aompietfJ and accurst. to the be.t of my know/edg., I aCHnow/edge that th. flnancI.1 report wl/l b. completed end retumtd Bo.rd wit~ y.. of t~e date of our g8mbllng letlvlty. Chief executive officer's signature . 54 ".1. c Oat. I 5'/ ;;.oJO CompleW . ..p....te application for e.ch gambln; activity: Financial report and record keeping required .. one day of gambling activity, A tlnanclal report form and Instructions will be .ent with .. two or more consecutive days of gambling ac:tlvity, your permit, or use the online flll..in form av.i1able at .. each day a raffle drawing is held www.gcb.state.mn.us. VVlthin 30 days of the activity date, Send application with: complete and retum the financial report form to the .. a copy of your proof of nonprofit status, and Gambling Control Board, .. application fee for each event. Questions? Make check payable to "State of Minnesota," Call the Lic:enslng Section of the Gambling Control Board at 651-639-4076, To: Gambling Control Board 1711 West County Road B. Suite 300 South I ROlevllle. MN 55113 Print Form Reset Form Data privacy. Thl. form wiD be made aVlUable the BolI'd witI be abla to procasa your In .mat/Va fo""at (I.a.larga P""t, BratHa) applIC8tlon, Your nama and and your upOn raqueet. Tha information raqullltltd On organlallon" name ."d Iddl'lll win be public thlt fl:lrm (Ind ."y ettachm."lI) wi. be u..d by Infofmatian when I'WClIIvad by \hI hII'd. All \hI GlImbllnQ Control BCltlret (Baaret) to \h. othtl' In1Qrmallon yOU provide will be privata dalar'mlnl your qualiftClltIGnl to be InVQlvad In dlla until t/'ll Saard llsu.. your permit. \Ml." IawNI gambling actMllaa In MlnnllOla. You the Solii'd '..u.. your plImlit, all of thl hll/ll \hI ri;ht to retl.l.. to supply ttla In1omlltton provtGed to tha BoIrct win becoma Informallon raqu..ted; however, If you retl.l.. to public. If the Board doel not lllUa . permit. all 1UPP!Y Ihillnftlrmallon the BOlrd may not be In10mlattan proIIlded ntml'nl p"Vlte, with the able to datermlnl YOIJr' Quallf\aatlonl and, II a Ixcapdon of your nama Ind your orglnization'. conaaqUlnca, m.y refilM to lnue you I pe""1t. nl1Ma and addl'Ull which willl1llTllln public. If you supply thl Information requ..tld, PMtII d.tII are lvallable to: BOIrd members, Board alaff WhOM ~ rtQulru aeee.. to thl Info""ation; MlnnallOla" Oeplrtmant of ~bllc S.fltV: Attomey Ganlll'l~ Commlaalonll'l of Administration, FInance, I"d ".venuI: I.eglslatlva Auditor, nattonal .nd Intematlcu14l gamblinG re;ulatClfY a;an"l; anyone llul'1ulnt to court ordlr, otntl' IndlYtdl.lala and laaneiaa th8t al'l apaclflcelly luthorlaed by llate or federellew to have Iccaa. to tha Infonnatlon; Indlviduala and agenci.. lor which Iew or lag.' order authorize. a naw u.. or ..,.ring of Information after thla Notice wa. given: and anyone with your conaent.