Agenda - Council - 04/12/2011 - Laserfiche WebLink

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LG220 Application for Exempt Permit LOCAL UNIT OF GOVERNMENT ACKNO'WLEDGMENT i . e aI If the gambling premises is within city limits, e 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 If the county taking A township application, The period. The gambling premises is located in a township, official must check the action that the county is on this application and sign the application. official is not required to sign the i 1 application is acknowledged with no wafting i application is acknowledged with e 30 day period, and allows the Board to issue a after 30 days. application is denied• name a waiting period, and allows the Board to issue a permit after 30 days (60 days for a let class city), The application is denied, waiting permit __ The Print county On behalf Signature Print city name of the county, I acknowledge this application. of county personnel receiving application On behalf of the city, 1 acknowledge this application. Signature of city pers noel receiving application Title Date Title P•PrNc.`/l CSt—, Date Li i5 r` / (Optionlai) acknowledge gambling statutory authority Statute 399.16E}1 Print township TOWNSHIP; On behalf of the township, t that the organization Is applying for exempted activity within the township limits. (A township has no to approve or deny an application [Minnesota name fpyX-p f Signature of township official acknowledging application Title 1 !_Date CHIEF EXECUTIVE OFFICER'S SIGNATURE Print.f4rm and. have CEO sign The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned o the Board within 30 days of the date of our gambling a hiefty. Chief executive officer's signature^' Date Conrpleta a separate applicatlon for each gambing activity: • 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 171 W . est County Road t3, Suite 300 South Roseville, MN 55113 Financial report' and recordkeep ng req ilred A fi ancial report form and instructionswill• 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. Questions? Call the Licensing $econ of the Gambling control Board at 651-639-4040. This form win be mado availabl i tematsve format (i.e, large print, t3railie) 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; howeve r, if your organization refuses tosupply 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 your organization supplies 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 dataabout your organization 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 dataabout your organization areavailable to: Board members, Board staff whose work requires access to the information; Minnesota's Department of Publlc 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 oriegal'order authorizes a new use or sharing of information atter this notice was given; add anyone with your written consent,