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<br />is this gambling premises located within city limits? If Yes, write the name of the City{F9
<br /> City Name O',,a/~. 5e..7
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<br />Yes F--I No
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<br /> If No, write the name of' the County and the Township:
<br /> County Name Township Name
<br />Check the appropriate status of the Township: I--] organized [--] unorganized [--I unincorporated
<br />
<br />1. The city must sign this application if the gambling
<br />premises is within city limits.
<br />2. The county and township must sign this applica-
<br />tion if the gambling premises is not within city limits.
<br />
<br />3. DO NOT submit this application to the Gambling Control.
<br />Board if it is denied by the local unit of government.
<br />4. NOTE: A Township may not deny an application.
<br />
<br />Upon submission of this application to the Gambling Control Board, the exemption will be issued not
<br />r,',ore ,, ,~,,.,., dayct~,-'~" ,,.,J~ '~ ..... ~"r.~ ..,,;*I~'~' ................... o¢ ;ha ~ ¢* ,-~-) fm.m the _,'late thc. ~ocal unit of aovemment..
<br />signed the application, provided the application is complete and all necessary information has been
<br />received, unless the local unit of government passes a resolution to specifically prohibit the activity. A
<br />copy of that resolution must be received by the Gambling Control Board within 30 days of the date
<br />filled in below. Cities of the first class have 60 days in which to disallow the activity.
<br />
<br />City or County Acknowledgment of Receipt of
<br />Application
<br />Si~3{ure_of person r.~eivinglapplication
<br />
<br />Date Received:
<br />
<br />Township Acknowledgment of Awareness of
<br />Application
<br />Signature of person acknowledging application
<br />
<br />Date Signed:
<br />
<br />Title of person acknowledging application
<br />
<br />Title of person receiving application
<br />
<br />I have read this application an8 all information is true, accurate and complete.
<br />
<br /> e,,~-r,,:* *k-, ,[,pl~,-.-,ti~r, ~t least 45 days palette ye. ur *r. hed,,~¢a date ¢,f activitv
<br /> Be sure to attach the $25 application fee and a copy of your proof of nonprofit status.
<br />
<br /> Mail the complete application and attachments to:
<br /> Gambling Control Board
<br /> 1711 W. County Rd B Suite 300S
<br /> Roseville, MN 55113
<br />
<br />This publication will be made available in alternative format (i.e..large Pdnt, braille) upon request.
<br />Questions on this form should be directed to the Licensing Section of the.Gambling Control Board at
<br />(612)639-4000. ' -
<br />Hearing impaired individuals using a TDD may call the Minnesota ~,elay Service.afl-800-627-3529 in the
<br />Greater Minnesota Area or 297-5353 in the Metro Area. ..:,. ' '
<br />
<br />lhe information requested on this form will be used .lay. the Gamblinij c.0n~ro~t3oard.(GC~) to determine your
<br />compliance with Minnesota Statues and rules governing lawful gambl!pg act'i~tities. All of the information
<br />that you supply on this torm will become public information when reCeived by the GCB.
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