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LG220 Application for Exempt Permit <br />Organ,zal,on Name ' <br /> <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises is within city limits, the <br />city must sign this application. <br /> <br />On behalf of the city, I acknowledge this application. <br /> <br /> Check the action that <br /> the city is taking on this application. <br /> <br /> The city approves the application with no <br /> waiting period. <br /> <br />The city approves the application with a 30 day <br />waiting Period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city). <br /> <br />DThe city denies the application. <br />Print name of city,~' _ _~> ~.~,.z,, .:i' '~,'~ ~ <br />(Signature of city personnel recelwng apphcat~on) <br /> <br />Page 2 of 2 <br /> 12/03 <br /> <br />If the gambling premises is located in a township, both <br />the count,.,, 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 applic.afion. <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 />The county 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 />Title <br /> <br />Oate "~/ / <br /> <br />Chief Executive Officer's Signature <br />The information provided'~-n--~is'-~' 'cati 'comp. le~t~e 8 d .acc_;urate to the best of my knowledge. <br /> <br />Chief executive offiger's signatur~/ <br /> <br /> '' <br /> <br />Mail Application and Attachments <br />At least 45 days prior to your scheduled activity date send: <br /> the completed application, If your application has not <br /> a copy of your proof of nonprofit status, and been acknowledged by the <br /> · a $50 application fee (make check payable to "State of Minnesota"). local unit of government or <br /> Application fees are not prorated, refundable, or transferable, has been denied, do not <br /> Send to: Gambling Control Board send the application to the <br /> 1711 West County Road B, Suite 300 South Gambling Control_Board. <br /> Roseville, MN 55113 ' <br /> <br /> <br />