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LG220 Application for Exempt Permit 1/13 Page 2 of 2 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT CITY APPROVAL for a gambling premises located within city limits he application is acknowledged with no waiting period. 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 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. period, and allows the Board to issue a permit after 30 days. The application is denied. Print city name L- ° 4-1 ®C Vac.l.-r1 S Q ti Print county name Signature of city rsonnel % I // nV1`IJ _ /_'�-1 Signature of county personnel n� Title ��/I.ti�� Ida �c�J Date I/ �/`� Title Date LI tt O Htr1 TOWNSHIP. If required by the county. 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, per Minnesota Statutes 349.166.] Print township name Signature of township officer Title Date CHIEF EXECUTIVE OFFICER'S SIGNATURE 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 and returned to the Board within 30 ys of the event date. Chief executive officers signature /%pr, /' f Date / 3W9--- Print name I) S$ Al. 1-4/ ,1 REQUIREMENTS Complete a separate application for: • all gambling conducted on two or more consecutive days, or • all gambling conducted on one day, Only one application is required if one or more raffle drawings are conducted on the same day Send application with: _ a copy of your proof of nonprofit status, and application fee (non refundable). 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 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 651-539-1900. This form will be made available in alternative format (i.e, large print, Braille) upon request. Data privacy notice: The Information requested on this All other information provided will be pri- General; Commissioners of Administration, form (and any attachments) will be used by the Gambling vate data about your organization until the Minnesota Management & Budget, and Control Board (Board) to determine your organization's Board issues the permit. When the Board Revenue; Legislative Auditor, national and qualifications to be involved in lawful gambling activities in issues the permit, all information provided international gambling regulatory agencies; Minnesota. Your organization has the right to refuse to will become public. If the Board does not anyone pursuant to court order; other indi- supply the information; however, if your organization Issue a permit, all information provided viduals and agencies specifically authorized refuses to supply this information, the Board may not be remains private, with the exception of your by state or federal law to have access to able to determine your organization's qualifications and, organization's name and address which will the information; individuals and agencies as a consequence, may refuse to issue a permit. If your remain public. Private data about your for which law Or legal order authorizes a organization supplies the information requested, the Board organization are available to: Board mem- new use or sharing of information after this will be able to process the application. Your organization's bers, Board staff whose work requires notice was given; and anyone with your name and address will be public information when received access to the information; Minnesota's written consent. by the Board. Department of Public Safety; Attorney