Agenda - Council - 06/22/2010 - Laserfiche WebLink

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'\'" J LG220 Application for Exempt Permit Page 2 of 2 1/10 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the gambling premises is located in a township, a a city official must check the action that the city is county official must check the action that the county is taking taking on this application and sign the application. on this application and sign the application. A township official is not required to sign the application. ~he application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. . -==- The application is acknowledged with a 30 day waiting _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 days (60 days for a 1 st class city). days. _The application is denied. _The application is denied. Print city name C";. -\-"'1 of- l2o...M.~ Print county name On behalf of the county. I acknowledge this application. On behalf of the city, I acknowledge this application. Signature of county official receiving application Signature of city offioial receiving application J;) ~~ -- ~ Title Date -1-1- ~ ,~c..R. Date 0 I 151/0 (Optional) TOWNSHIP: On behalf of the township. I Title acknowledge that the organization is applying for exempted gambling Ofh~- activity within township limits. [A township has no statutory authority to approve or deny an application [Minnesota Statute 349.166)1 Print township name Signature of township official acknowledging application Title Date _1-1- CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial rep~rt will be com~/eted and ~o tjY;;.!!!in 30 days of the date of our gambling activit Chief executive officer's signature . Date 6// J I V Complete a separate application for each gambing activity: Financial report and recordkeeping required - one day of gambling activity, A financial 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, Send application with: complete and return 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 Licensing Section of the Gambling Control To: Gambling Control Board Board at 651-639-4076. 1711 West County Road B, Suite 300 South I Print Form I I Reset Form I Roseville. MN 55113 This form will be made available in alternative format (Le. 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 activities in Minnesota. Your organization has the right to refuse to supply the information requested; however. if your organization refuses to supply this information. the Board may not 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. 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 Department of Public Safety; Attomey General; Commissioners of Administration. Minnesota Management & 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 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.