Agenda - Council - 07/12/2011 - Laserfiche WebLink

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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. he application is acknowledged with no waiting period. The application is acknowledged with a 30 day If the gambling county official taking on A township application. The premises is located in a township, a must check the action that the county is this application and sign the application. official is not required to sign the application is acknowledged with no waiting application is acknowledged with a 30 day period, and allows the Board to issue a after 30 days. application is denied. name period. The waiting permit The waiting period, and allows the Board to issue a permit after 30 days (60 days for a 1st class city). The application is Print county On behalf Signature denied. p Print city name L.01 c " y cx-0 of the county, I acknowledge this application. of county personnel receiving application On behalf of the city, I acknowledge this application. Signature of city personne receiving application Title Date Title r• rw"-n�— Date 4 / /a 3 / (Optional) acknowledge gambling activity statutory authority Statute 349.166)] Print township TOWNSHIP: On behalf of the township, I that the organization is applying for exempted within the township limits. [A township has no to approve or deny an application [Minnesota name 0) ,t^ Signature of township official acknowledging application Title Date CHIEF EXECUTIVE OFFICER'S SIGNATURE Print form and have CEO sign The information provided in this application is complete and that the financial report will be comp d and returne to activity. Chief executive officer's signature accurate to the best of my knowledge. I acknowledge the Board within 30 days of the date of our gambling Date 6 4 0 / Complete a separate application for each gambling event: • 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 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. Questions? Call the Licensing Section of the Gambling Control Board at 651- 639 -4000. 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 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. 5/11 esef For