Agenda - Council - 03/22/2011 - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of 2 1/11 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, a city official must check the action that the city is taking on this application and sign the application. 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 (60 days for a 1st class city). The application is denied. Print city name sz.f On behalf of the city, I ac nowledge this application/ Signature of city official receiving application Titles Date /1 / If the gambling premises is located in a townshi p, a county official must check the action that the counts taking on thi application and sign the application. A town hip official is not required to sign thp'application. The a lication is acknowledged with waiting period. The appation is acknowledged wit a 30 day waiting period, an allows the Board to is ue a permit after 30 days. The applicatio is denied. Print county name On behalf of the county, ackn wledge this application. Signature of county officia eiving application Title (Optional) TOW I SHIP: On behalf of the .wnship, I acknowledge that t'e organization is applying for empted gambling activity within tow ship limits. [A township has no sta tory authority to approve or d: y an application [Minnesota Statute 34` 166)] Print towns p name Signat e of township official acknowledging application Titl Date / / CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application financial report will be completed and ret Chief executive officer's signature ompl -.t curate to the best of my knowledge. I acknowledge that the e Boarthin 30 dfiys of the date of our gambling activity. Complete a separate application for each ga • ing - 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. Make check payable to "State of Minnesota." To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 activity: Date 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. Print Form Reset Form This form 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 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; Attorney 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.