Agenda - Council - 02/26/2013 - Laserfiche WebLink

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Chief executive officer's signature Complete a separate application 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 1711 West County Road B, Suite 300 South Roseville, MN 55113 This form will be made available in altemative format (Le. 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 requested; however, 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 you supply the information requested, LG220 Application for Exempt Permit Page 2 of 2 1/10 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the gambling premises is located in a township, a a city official must check the action that the city is county official must check the action that the county is taking taking on this application and sign the application. 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. _ he 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 e-t / pit- On behalf of the city, I acknowledge this application. Signature of city official receiving application Title 1-; out-44 ? 01 Pate L / / `) /3° CHIEF EXECUTIVE OFFICER'S SIGNATURE The information is financial report ll be completed and returned to the Board within my knowledge, 30 days of the dateofourgambling activity.acknowledge that the p application will p Date 0,0 /1/43 Financial report and recordkeeping required A financial report form and instructions wilt 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 651-639-4076. 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 On behalf of the county, I acknowledge this application. Signature of county official receiving application Title Date / / (Optional) TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within 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 / / miniemeromeramm IPrint Form ( I Reset Form I the Board wit 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 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 data 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.