Agenda - Council - 08/24/2004 - Laserfiche WebLink

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LC220 Application for Exempt Permit Organization N a me~_i~Tl-'~ ~ ~/ [,t~f'~ ¢.- Local Unit of Government A~knowledgment If tile gambling premises is within city limits, the city must sign this application. On behaff of Ihe city, I acknowledge this application. Check the action that the city is taking on this application. The city approves the application with no waiting period. The city approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city). E]The city denies the application. Print na~e of city C'.', '~"~, c:~ fSignature of city personnel receiving application) Page 2 of 2 6103 If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county is taking on this application. DThe county approves the application With no waiting period. DThe county the application with a 30 day approves waiting period, and allows the Board to issue a permit after 30 days. BThe county denies the application. Print name of county (Signature of county personnel receiving application) qtle ~ate / / TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. [Atownship has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2).] Print name of township (Signature of township official acknowledging application) ~tle Date / Chief Executive Officer's Signature - The information provided in this application is complete and accurate to the best of my knowledge. Chief executive officer's signature Name (please print)_ Date__/__ Mait Application and Attachments At least 4,5 days prior to your sct~eduled activity date send: the completed application, · a copy of your proof of nonprofit status, and · a $50 application fee (make check payable to "State of Minnesota"). Application fees are not prorated, refundable, or transferable. Send to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 If your application has not been acknowledged by the local unit of government or has been denied, do not send the application to the Gambling Control Board.