Agenda - Council - 05/17/2011 - Special

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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 perod, and allows the Board to Issue a permit after 30 days (60 days for a ist class city). The application is denied. Print city name _ __ _ ___ ___ _ ___ — _ - -- If the gambling premises is located in a township, a county official must check the action that the county is taking on this application and sign the application. A township official is not required to 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 perm after 36 says. The app plicfation Is denied. Print county name _ - - - - On behalf of the county, T acknowledge this application. . Signature of county personnel receiving application On beha /f of the city, I acknowledge this application. Signature of city personnel receiving application - -- _ - - - -- Title Date Title Date _- - _ (Optionial) TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the 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 SIGNATURE Print form and have CEO sign The Information provided In thls application Is complete and that the financial report' will be completed an• turned Chtivity, � G+l� (X, ... Chief executive officer's signature 11 .:r accurate to the best of my knowledge. I acknowledge the Board wit In 30 days of the date of our ambling r 4 , ate D ate =� � - Ill or Complete a separate application for each gamblin vent: • 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 Financial report and record keeping 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. Questions? Call the Licensing section of the Gambling Control Board at 6S1- 6394000. LG220 Application for Exempt Permit 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; howeve r, 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 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 data about 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. Page 2 of 2 5/11 Private data about your organization 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 Reset Fot n