Agenda - Council - 03/23/2010 - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of 2 7109 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMEN If the gambling premises is within city IIIII&-,, a city official must check 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 The application is denied. Print city name Q`" On behalf of the city, t acknowledge thrs appl ation Signature of city official receiving application (Optional) TOWNSHIP' On behalf of the township, I � ✓ pate acknowledge that the organization is applying for exempted gambling Title - - -- - - - - -- -- - - - - -- 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 _ -_ - -- - - - - -/- CHIEF EXECUTI O FFICER'S SIGNATURE The information provided in this application is c to and accurate to the best of my knowledge. I acknowledge that the financial report will be completed an ( ed to th Board within 30 days of the date of our gambling activity. Chief executive officer's signature - - _ f! (2 �� Date Complete a separate application for e\acfS 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 - application fee for each event. Make check payable to "State of Minnesota." To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 If the ' =in,l:iir'��.i I�r I:tNi,,t:':_ '.- is :ai,A In ;a a county official must check the action that the county is taking on this application and sign the application. A township official is not required to 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. __ - The application is denied. Print county name On behalf of the county, t acknowledge this application. Signature of county official receiving application Financial report and recordkeeping required A financial report form and instructions will be sent with your permit, or use the online fill -in form available at www.gcb- state.mn.us. 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. Fi►1 -in =&P int Form Reset Form Data privacy. This form will be made available in alternative format (i.e. large print, Braille) upon request. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a permit. If you supply the information requested, the Board will be able to process your application. Your name and and your organization'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.