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LG220 - Application for Exempt Permit <br />Organization Name <br /> <br />Local Unit of Government Acknowledgment <br /> <br />Page 2 of 2 <br /> 3/01 <br /> <br />If the gambling premises is within city limits, the If the gambling premises is located in a township, both <br />city must sign this application, the county and township must sign this application. <br />On behalf of the city, I acknowledge this application. On behalf of the county, I acknowledge this application. <br /> <br /> Check the action that <br /> the county is taking on this application. <br /> <br /> DThe county approves the application with no <br /> waiting period. <br /> <br />E] <br /> <br /> Check the action that <br /> the city is taking on this application. <br /> <br />The city approves the application with no <br />waiting period. <br /> <br />The city approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city). <br /> <br />The city denies the application. <br /> <br />DThe county the application with a 30 <br /> approves <br /> day <br /> waiting period, and allows the Board to issue a <br /> permit after 30 days. <br /> <br /> The county denies the application. <br /> <br />Print name of city ~,'~---~ ~ <br /> <br />(Signature of city personnel receiving application) <br /> <br />Pdnt name of county <br /> <br />(Signature of county personnel receiving application) <br />Title <br /> <br />Date / / <br /> <br />TOWNSHIP: On behalf of the township, I acknowledge that <br />the organization is applying for exempted gambling activity <br />within the township limits, lA township has no statutory <br />authority to approve or deny an application (Minn. Stat. sec. <br />349.213, subd. 2).] <br />Pdnt name of township <br /> <br />(Signature of township official acknowledging application <br />Title <br /> <br />Date / / <br /> <br />Chief Executive Officer's Signature <br />The information provided in this apron ~/~m¢~d a~urate to the best of my knowledge. <br />Chief executive officer's signature ' ";--/-¢e,~-'"/:¢// //~ <br /> / / <br /> // <br />Name (please print) '-~-'o'~e__~5/'J~ )~- ~'-oi/tS?~ ,/- Date ~_ //,~--I4)/._~_ <br />Mail Application and Attachments <br /> <br />At least 45 days prior to your scheduled activity date send: <br /> · the completed application, If your application has not <br /> · a copy of your proof of nonprofit status, and been acknowledged by the <br /> · a $25 application fee (make check payable to "State of Minnesota"). local unit of government or <br /> Application fees are not prorated, refundable, or transferable, has been denied, do not <br /> Send to: Gambling Control Board send the application to the <br /> 1711 West County Road B, Suite 300 South Gambling Control Board. <br /> Roseville, MN 55113 <br /> <br />07- <br /> <br /> <br />