Agenda - Council - 06/08/2010 - Laserfiche WebLink

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LG220 Application for Exempt Permit If the gambiiFlg premises is located in a township, 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. LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is ~vitltin city limits, a city official must check the action that the city is taking on this application and sign the application. ~Ti~te application. is acknowledged with no waiting period. -Tile 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. _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. Page 2 of 2 1110 ll Print count name Print city name ~°~y 0 1- ~~ "^ ~ pn behalf oithe county, I acknowledge this application On behalf oithe city, ! acknowledge fhrs application. Signature of county official receiving application Signature of cit official receiving applica ' f..w•--~•- Title ~~ Title ~ ~ ~'`~"~- Date ~ ~ / ! J ~-~`~ ~f to (Optional) TOWNSHIP: On behaltof 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 applir;alion [Minnesota Statute 349.166)) Print township name Signature of township official acknowledging application Title Date / / CHIEF EXECUTIVE OFFICER'S SIGNATURE The rnformafion provided in this application is complete and accurate to the best of my knovrledge. I acknowledge that the financial report will be completed and return o~th~ Board within 30 days of the date of our gambling activity. Chief executive officer's signature ; ;u,r.. `c..~t ~ Datev~'i ~~ /D.•~ / I C' Complete a separate application for each 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. tvtake check payable to "State of Minnesota." To: Gambling Control Board 1711 West County Road B, Suite 300 South Ftosevrlle, MN 55113 Print Form Reset Form This farm will be made available in alternative format (i e. large print, Braille) upon request. Data privacy notice;The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your organization's qualifications to be involved in lawful gambling activdres in Minnesota. Your organization has the right to refuse to supply the information requested; however, i1 your organization refuses to supply this information, the Board may no[ be able to determine your organization's qualifications and, as a consequence, may refuse to issue a permit. If you supply the information requested, the Board will be able to process your organization's application. Your organization's name and address will be public information when received by the Board. All 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. It 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 Department of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management 8 Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies: anyone pursuant to court order; other individuals and agencies specifically authorized by state or federal law to have access to the information; individuals and agences 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. 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.