Agenda - Council - 07/13/2010 - Laserfiche WebLink

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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. Y ' 1 The 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 fora 1st class city). days. _The application is denied. _The application is denied. - Print city name ~C.~ of ~ Print county name On behalf of the county, I acknowledge this application. On behalf of the city, 1 acknouryledge this application. -Signature of county o~cial receiving application Si nature of cit official receivin lication a g y g pp ,ur„~` ~~..~ Title Date_/_/_ ,~+ Title t-~ hai~~-2 Date /~ / `~ (Optional) TOWNSHIP: On behalf of the township,) acknowledge that the organization is applying for exemptetl gambling ~~ ~ f- -- 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 S NATURE The informaticn provided in this applicatio is p/ to and accurate to the best of my knowledge. I acknowledge that the financial report will be completed an n t t Board within 30 days of the date of our gambling activity. .- Chief executive officer's signature Date ~ . ~ .. ( O Complete a separate application preach ga ing 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 fnancial 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 Roseville MN 55113 print Form Reset Form , This forth will be made available in alternative format (i.e. large pdnt, Braille) upon request Data privacy notice:The information requested on this forth (and any attachments) will be used by the Gambling Contrd Board (8card) 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, rf 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 he able to process your organization's appliption. Your organization's name and address will be public information when received by the Board. All other information provided will be pdvate 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 adtlress 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 Satery; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and intematlonal gambling regulatory agendes; anyone pursuant to court order, other individuals and agendes spedficelly authorized by state or federal law to have access to the information; individuals and agendes for which law or legal order authorizes a new use or shadng of information after this Notice was given; and anyone with your written consent.