Agenda - Council - 11/27/2012 - Laserfiche WebLink

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11/20/2012 12:12 3202598719 LG220 Application for Exempt Permit ',LOCAL ,UN.IT OF •C►OVE;RNMENT ACKNOWLEDGMENT The application is acknovl 'edged with no waiting period. . The application Is acknov■ 'edged with a 30 day waiting period, and allows the Bcard to Issue a permit after 30 days [60 days for a 1st class c ty], The application is denied. Print city name Signature Aclty personn Title D i 'tt� `U�/ Date_ 1112 -;t /'? CHIEF EXECUTIVE :OFFICER'S SIGN'ATU'RE The Information provided in th s application Is . report will be completed and niturned to . he Chief executive officer's signet ire ) Print name , iq �"da? R'EQUIREMENTS CITY APPROVAL fora gambling premises located within city limits Complete a separate application for - all gambling conducted on mi.) or more consecutive days, or - ell gambling conducted on on day, Only one application is requi If one or more raffle drawings are conducted on tie same day. Send application with: a copy of your proof of nonprofit status, and _ application fee, Make check payable to "State of Minnesota." To Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy notice: The Information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine 'four organization's qualifications to be Involved In lawfu gambling activities In Minnesota. Your organization has th a right to refuse to supply the Information; however, if our organization refuses to supply this Information, the Board may not be able to determine your organization'! qualifications and, as a consequence, may refuse to Isst e a permit„ If your organization supplies the Information requested, the Board will he able to process the applicatlor . Your organization's name and address will be public Information when received by the Board. FEDEX OFFICE Title Date PAGE 03/03 6/12 Page 2 of 2 COUNTY APPROVAL for a gambling premises located in a township 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, The application is denied. Print county name Signature of county personnel TOWNSHIP -If required by county, On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. [A township ha;; no statutory authority to approve or deny an application, per Minnesota Statutes 349,166,] Print township name Signature of township officer Title Date mplete and accurate to the best of my knowledge, I acknowledge that the financial d within 30 days of the event date, All other Information provided will be pri- vate 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 do!!s not Issue a permit, all information provided remains private, with the exception of your organization's name and address which will remain public, Private date about your organization are available to Beare mem- bers, Board staff whose work requires access to the Information; Mlnnesoti's Department of Public Safety; Attorney Date WO * � t tE 1�` ±!t ,iip6f;Il?Q4: wi?;iiTi ,, ;I1;!;11!ehlf :!I'tl1;bliil$bl� ;!k I „N; Ill In Ip�c, 4�.; t!; �.! iiel !tict:le4!i')t;�1�i(�1��I Financial report; and recordkeeping required A financial report form and instructions will be sent with your permit, or use thr:; online fill -In form available at www.gcb.state.m n.us, Within 30 days of the event 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. General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other Indi- vlduais 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 snaring of information after this notice was glven; and anyone with your written consent.