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LG220 Applicatioin for Exempt Permit <br />Organization Name ~ ~ <br />Local Unit of Goveirnment AcknOwledgment <br /> If the gambling premises Js within city limits, the <br /> city must sign this,a~plication. <br /> On beha f of th~ ~ tY,ilf~ acl{nowledge this application. <br /> r <br /> Check the .action that <br /> the city is ta~ng on this application. <br />'1~ The city approves the application with no <br /> waiting period, i <br /> <br />BThe city approve~ the;aPplication with a 30 day <br />waiting pedod, a~ld allows the Board to issue a <br />permit after 30 d~iys (60 days for a first class <br />city). <br /> <br />E~The city denies the aPplication. <br /> <br />Print name of city ~'~ ~'~_~. ~::,'~" ~--~:-,,._ksr-~ <br /> <br />(Signature of city personnel receiving application) <br />Title '~-~ .'~,.-,C~k.--~' ~ L ~.~, tr" <br /> <br />Date <br /> <br />Page 2 of 2 <br /> 06/03 <br /> <br />If the gambling promises is located in a township, both <br />the county and township must sign this application, <br /> <br />On behalf of the county, I acknowledge this application. <br /> <br /> Check the action that <br /> '~ the county is taking on this application. <br /> <br />county approves the application with no <br />ing period. <br /> <br />B ]nty approves the applic~ <br /> )edod, and allows the <br /> permit 30 days. <br /> <br />BThe denies the a <br /> <br />with a 30 day <br />to issue a <br /> <br />Pdnt name of county <br /> <br />Signature of <br /> <br />~tle <br /> <br /> / <br /> <br />nel receiving application) <br /> <br />TOWNSHIP: O .~[o~,nship, I acknowledge that <br />the organization/i4 ~ TOr exerh~ted gambling activity <br />within the town/~h [Atownshl~,has no statutory <br />authodtyto a,~'prove or deny an application (Minn. Stat. sec. <br />349.213, sLbd. 2).] <br /> af township <br /> of township official acknowledging a'~cation) <br /> <br />Date / / <br /> <br /> r <br />Chief ExecUtive OffiCer's Signature <br />The information ProVided in this application ~'inp!et/e/,/and accurate to the be~_~of my knowledge. <br /> <br />Mail Application and A~achmen~ <br />At least 45 days pd0r~to your scheduled a~ivEy date send: · the complete~ application, <br /> · a ~py of your: Pm0f of nonproffi ~atus, and <br /> · a ~eck for ~. Make che~ payable to "~ate of Minnesota". <br /> Appli~tion fees a~ not prorated, refundable, or transferable. <br /> Send to: 6am~lin~ Co.roi B~rd <br /> 17{~ ~e~ Cou~ Road B, Sure 300 South <br /> Ro~ille'; MN 55113 <br /> <br /> <br />