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LG220 Application for Exempt Permit <br /> <br />_ocal Unii of GoYernment Acknowled§rnent <br /> <br />If the gambtin!.j premises is within city limits, the <br />city must sign thi.~ application. <br /> <br />On behalf of I:h::; (it), I acknowledge this application. <br /> <br /> Check the action that <br /> the oily i.,. takin9 on this application. <br /> <br />The ci!y ai?m/~'s the application with no <br />waitin9 i~e~ <br /> <br />D <br /> <br />The city ;q¢f~ ow's the application with a 30 day <br />waiting p~,iod: ~ncl allows the Board to issue a <br />permit uti. er :",Q (Fays (60 days for a first class <br />city). <br /> <br />DThe cily d,~n~es the application. <br /> <br />(Signature of c~;:? pcrso~nel receiving application) <br /> <br />Page 2 of 2 <br /> 12/03 <br /> <br />If the gambling premises 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 />DThe county approves the application' with no <br />waiting period. <br /> <br />DThe county approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days. <br /> <br />DThe co.unty denies the application. <br /> <br />Print name of county <br /> <br />'(Signature of county personnel receiving application) <br />Title <br /> <br /> Date / / <br /> <br />TOWNSHIP: On behalf of the township, I acknowledge that <br />the organization is applying for exempted gambling activity <br />within the township limits. [Atownship has no statutory <br />authority to approve or deny an application <br />(Minnesota Statute 349.213, subd. 2).] <br />Print name of township <br /> <br />(Signature of township official acknowledging application) <br /> <br />Title <br /> <br />Date__l__/__ <br /> <br />Chief Exe(:utive Officer's Sigriature f / <br />The inform~¢i~,, i:,rnv,ded in this appli~atioa i.¢ com~lete~.~.~ccurate to the best of <br /> <br />Chief executive o,ffic~,r's signature <br /> <br />my knowledge. <br /> <br />Mail Appiication and Attachments <br /> <br />At least 45 d~.ys ?ira to your scheduled activity date send: <br /> the cr,nqXeted application, <br /> a c~py .f your p~oof of nonprofit status, and <br /> a $50 ~,.pptication fee (make check payable to "State of Minnesota"). <br /> Appli<[ti,-,r~ fl:es are not prorated, refundable, or transferable, <br /> <br /> Send to: (;an,bling Control Board <br /> !7I' West County Road B, Suite 300 South <br /> l::'.os,;ville, MN 55113 <br /> <br />If your application has not <br />been acknowledged by the <br />local unit of government or <br />has been denied, do not <br />send 'the application to the <br />Gambling Control Board. <br /> <br /> <br />