Agenda - Council - 05/27/2014 - Laserfiche WebLink

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LG22p Application for Exempt Permit LOCAJL UNIT OF GOVERNMENT ACKNOWLEDGMENT CITY APPROVAL for a gambling premises located within city limits X_ The i-- pplication is acknowledged with no waiting period. __The uplicatIon is acknowledged with a 30 day waiting perioi, and allows the Board to issue a permit after 30 days [60 rays for a 1st class City]. The application is denied, ,,i,.....\ Print city name i Signaturci of city pwnnel /' Title r-- 1 /1',--.‘c-.37-._ Date pi /".e it.*_ni unit Ut gnUUrnment must 91911 1/13 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. IThe application is denied. [ Print county narne !Signature of county personnel :Title Dale ) 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 .1 Print township name Signature of township officer 'Title CHIEFt EXECUTIVE OFFICER'S SIGNATURE The inforriation provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report witbe completed and returned o the Board within 30 days of the event date; Chief exeutive officer's signature 14-(— Dote Print name •--jt >Y1 REQU REMENTS Complete a separate application for; • all gam ?ling conducted on two or more consecutive days, or • all gambling conducted on one day, Only on'r.., application is required if one or more raffle drawings are conducted on the same day Send application with: a copykif your proof of nonprofit status, and application fee (non refundable). Make check payable to "State pi Minnesota," To: Gambling Control Board 1711 West County Road B, Suite 300 South Roseille, MN 55113 Data nrivac notice; The information requested on this form (and any attachments) will be used by the Gambling Control Bo4d (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 l!iforrnahon; however, if your organization refuses to s pply this information, the Board may not be able to deteinine your organization's qualifications and, as a conseg ronce, may refuse to issue a permit. II your organizatior supplies the information requested, the Beard will be able 0 process the applicaticm, Your organIzation's name and a:10ress will be public infoi motion when received by the F.ioard. Date Financial report and recordkeeping required A financial report form and instructions will be sent with your permit, or rise the online fill-in form available at www.gcb.state.ron.us. Within 30 days of the event date, complete and return the financial report fornri 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 foi mat (I.e. large print, Braille) upon request. 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 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 about your organization are available to: Board mem hers, Board staff whose work requires access to the information; tAinnesota'f, Department of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; legislalive Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other indi- viduals and agencies specifically authorized by state oi 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.