Agenda - Council - 04/27/2010 - Laserfiche WebLink

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LG220 Application for Exempt Permit If the gambiirg LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, a city official must check the action that the aty is taking on this application and sign the application. ~he 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 fora 1st class city). _The application is denied. Printatyname C-~~'~` O~" ~"~~ On behalf of the city, I a owledge this application. Signature(o~f city official receivin~pliQcation C~J -- ~ \ ~ C Title ~ Date / 1 C ! °Z~ ~ O Page 2 of 2 1110 is located in a township, a county official must check the action that the county is taking on this application and sign the appligtion. 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, 1 acknowledge this application. Signature of county offitdal receiving appliption Title Date / 1 (Optional) TOWNSHIP: On behaN 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 / ! CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application is complete and accurate to the bast of my knowledge. l acknowledge that the frnancia! reporf wit! be completed and ~ ~ _ ~ ~~~ ~ bl' f~ Chief executive officer's signature- 30 days of a date of our gam rng ac rvrfy. ~1 Date t~ y ~ ! `~ ~ c~ (,~ ~ (,1 Complete a separate application for each gambing activity°~ Financial report and recordkeeping required - one day of gambling activity, A finanttial report form and instructions will be sent with -two or more consecutive days of gambling activity, your permit, or use the online fill-in form available at - each day a raffle drawing is held www.gcb.state.mn.us. Within 30 days of the activity date, complete and return the financial report form to the Send application with: - a copy of your proof of nonprofit status, and Gambling Control Board. - appliption fee for each event. Make check payable to "State of Minnesota." Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4076. To: Gambling Control Board 1711 West County Road B, Suite 300 South Print Farm Reset Form Roseville, MN 55113 This form will be made availab~ in alternative format (i.e. large print, Braille] upon request. Data privacy notlce:The information requested on this form (and any attachments) wiq be used by the Gambling Control Board (Board) to determine your organization's qualifications to be involved in tawful gambEng acfivities in Minnesota. Your organization has the right to refuse to supply the Information requested; however, if your organization refuses to supply this infortnalion, the Board may not be able to determine your organization's qualfiptions and, as a consequence, may refuse to issue a permit If you supply the iMOrmation requested, the Board will be able to process your organization's application. Your organization's name and address wiU be public information when received by the Board. AN other information provided will be private data until the Board issues the permit When the Board issues the permit, all information provided will become public. If the Board does not issue a permit, all information provided remains private, with the exception of 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 t?epartment of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agenaes; anyone pursuant to court order, other individuals and agencies spedfically authorized by state or federal law to have acaass iD 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 written consent