Agenda - Council - 02/14/2012 - Laserfiche WebLink

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LG220 Application for Exempt Permit 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 QF lec,pft On behalf of the city, I acknowledge this applicati Signature oftcity personnel;eceiing application n, Title 1-1i f\-(-‘A-"-e--.0 re-e_fonte (Optional) TOWNSHIP: On behalf of the township, I Page t❑f2 5/11 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 permit after 30 days. _wThe application is denied. Print county name On behalf of the county, I acknowledge this application. Signature of county personnel receiving application Title Date 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 this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed ... r- to the Board within 30 days of the date of our gambling activity. ► Chief executive officer1s signature"' Date / SOT — 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 0. 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. This form will be made available in alternative format (i.e. large print, Braille) upon request. Data privacy notice: The information Your organization's name and requested on this form (and any address will be public information attachments) will be used by the Gambling when received by the Board. All Control Board(Board)to determine your other information provided will be organization's qualifications to be involved private data about your. in lawful gambling activities in Minnesota. organization until the Board Your organization has the right to refuse to issues the permit, When the supply the information; howeve r, if your Board issues the permit, all organization refuses to supply this information provided will become information, the Board may not be able to public. If the Board does not. determine your organization's qualifications issue a permit, all information and, as a consequence, may refuse to issue provided remains private, with the a permit. If your organization supplies the exception of your organization's information requested, the Board will be name and address which will able to process your organization's remain public. application, 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. esel