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LG220 Application for Exempt Permit <br /> <br />Organization 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 t~king 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 8oard to issue a <br /> permit after 30 days (60 days for a first class <br /> city). <br /> <br />DThe city denies the application. <br /> <br />Pdnt name of city ~,.~"~V'~/ CY~ ! <br /> <br />D <br /> <br />(Signature of city personnel receiving application) <br /> <br />Page 2 of 2 <br />web 6/03 <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 the application with a 30 day <br /> approves <br /> waiting period, and allows the Board to issue a <br /> permit after 30 days. <br /> <br />DThe county denies the. application. <br /> <br />Pdnt 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 statutow <br />authority to approve or deny an application (Minn. Stat. sec. <br />349.213, subd. 2).] <br />Pdnt name of township <br /> <br />(Signature of township official acknowledging application) <br />Title <br /> <br />Date / / <br /> <br />Chief Executive Officer's $ign:-zture <br />The information provided in this application is complete and accurate to the best of my knowledge. <br />C hie f exe cuti ve office r's sig n a tu re,. ~,'¢)~1~--~-,..-.~ <br />Name (please print) rY~,~ ~.,~2~c ~4 .'~"~.~tvtK.2_- Date ~'2 /__~_/(;)¢ <br /> <br />Mail Application and Attachments <br /> ,;~, <br />At least 45 days prior to your scheduled activity date send: <br /> the comple~gd application, <br /> · a copy of your proof of nonprofit status, and <br /> · a check for $50. Make check payable to "State of Minnesota". <br /> Application fees are not prorated, refundable, or transferable. <br /> <br /> Send to: Gambling Control Board <br /> 1711 West County Road B, suite 300 South <br /> Roseville, MN 55113 <br /> <br /> <br />