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LG220 Application for Exempt Permit <br />Page 2 of 2 9109 <br />LOCAL UNIT OF GOVERNMENT ACKNOW LEDGMENT <br />ff the gambling premises is within city limits, M the gambling premises is located in a township, a <br />a city official must check pC) the tictlon that the courtty official must check (X) the action that the county <br />cky is taking on this application antl sign the is taking on this application and sign fire application. A <br />application. township oiBelal must also sign the application. <br /> <br />The application t5 acknowledged with no waiting period. The application is acknowledged with rto waiting period. <br />e application is adutowledged with a 30 day waiting The application is acknowledged with a 30 day waling <br />period, and aibws the Board to issue a permit after 30 period, ant alkrws the Board to issue a permR after 30 <br />days (60 days for a 1st doss katy). days. <br />The application is d <br />emed. _TFre application is denied. <br />e <br />Print ctY name L'.T r`/ O~ <br />On behalf of the city <br />1 wledge this applicatan Print munty name <br />On behalf of the county, I acknowledge this appfrcatan. <br />, Signature d county official receiving application <br />Signature of sty offlcal rvirtg application <br /> <br />t--r~-~. Title Dale / / • <br /> <br />~/ <br />TNe ~ ~/~wr~ c5C Date l / 3`J/ t' ~ TOWNSHIP:On behalf aftlte township, I atlmowiadge that <br />ske organaation is applying for exempted gambling ac9vily <br />~i ~~ --- within township limits. (A township has m stakdory autltority to <br /> approve a Berry an appgraBan pAinnesote SlaWte 348.273, strhtl. 2)] <br /> Print township name <br /> Signature of township offical acknowledging application <br /> Title ~ Date / / <br /> <br />CHIEF EXECUTIVE OFFICER'S SIGNATURE <br />The information pmtrided in this application is complete and aawrate fo the best of my Ivawkdge.7 adotowledge }hat the <br />finankia! /sport will be completed and returned to the•Bcani within 30 days of the date ofourgamblirg ac6vily. <br />~J~ !; ~9 <br />Chief executive officer's signature 7f.(.-;~i7/, i.S~„G2~-, Date 1-/// %/O <br />Comptehe a separate application for each gambing activity <br />d Financial report and recordkeeping <br />- one <br />ay of gambling activity, required <br />-two or more wnsewtive days of gambling activity, A finankdal report form and inshuctiorts will be <br />- each day a raffle drawing is held sent with your permit Within 30 days of the <br />Send a Ication with: a <br />ppl Dopy of your proof of nonprofd status, a~vrtY ~~~ template and return the finandal <br />rtaport form to the Gambling Control Board <br /> <br />and $50 application fee for each event Make check payable to . <br />"State of Minnesota,' QuesBOrra9 <br /> Call the Licensing Staction of the Gambling <br />To: Gambling Control Board Control Board at 651-639-4078. <br />1711 West County Road 8, Suite 300 South <br />Rosevile, MN 55113 Print Form peset Form <br />Data privery. Thisform call he made avapahle in the Board wit be abbbprocess YOw <br />akematlvefamat (Le.Wge Mks. Braae)rgon apPiradon. Your rrwne end end your <br />request The kdamatbn requested on this tam onPrrimSon's name and address call be public <br />(and arryatbchmems)w91 he used by We trrfamation when reoaivatl by the Board. M <br />Gambifrg Control sward (!bard) to detemrkre yow ~ aster CltPrrrratian You provide wiN be private <br />qual9lodommheinvaNed blasvful gambling date urrsl the Board issues yore permit yNren <br />actlvales in Minnesota. You havethe rrgMto IM board issues your Permit eX of the <br />refuseto supplyltre informatlon requested; infarnation provided to the Bond wit become <br />however, ryou n:fusemsrgrplythlslMormatbn, Public athe Board doss not isguea Permit ant <br />the Board may nit be abkmdetcrmce your nfamation provitlad remains prvate, wih the <br />qualNiolions and. ass consequence. may rehase exception of yorurwne and you organvetion's <br />to ¢sueyoua perms. Hyou suppythe nano ant address which wit remain public <br />intormatbn requested, PIIY8IB data ere eveibbla to: Board members, <br />Board sniff wlwae wok recpire8 access to the <br />intorrrre5on; MinrresMa'a Depararrerrt of Public <br />Safely; Attorney Gerraral; Carrlmissioners of <br />Administralton, Frrence, and Revenue; <br />Legislative Autlibr, rratiorml and'urtamatiprret <br />9amtling ragWatory agendas; anyag Pkasrrent <br />to carat order, other indivWuab end agendas <br />tltet are spetlfiealy au9rorized by state a <br />federal law b have access to 9ra ifi(Orrnation; <br />hldviduab arq agendas for vrhidr lekv a legal <br />order eulha¢es a new use a sharing of <br />information attar this notica was given: ant <br />anyale Wig! Your COrgant <br />