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LG220 Application for Exempt Permit~ <br />Organization Name . : <br /> <br />Page 2 of 2 <br /> 11/04 <br /> <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises is within city limits, tl~e <br />city must sign this application. , <br /> <br />On behalf of the city, I acknowledge this applicatiom <br /> <br /> Check the action that <br /> the city is taking On this application. <br />rlwhaecity approves application no <br /> the <br /> with <br /> iting period. <br /> <br /> The city approves the application with a 30 day <br />D 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 /> <br />P nt e o, city C: <br />Signature of city personnel receiving application <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 />OThe county denies the application. <br /> <br />Pdnt name of county <br /> <br />Signatur.e 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 We township limits. [Atownship has no statutory <br />authority to approve or deny an application <br />'Minnesota- Statute 349.213,.subd. 2).] <br />Pdnt name of township <br /> <br /> ~ Signa~re of township official acknowledging application <br /> ~tle <br /> <br /> Date / / <br /> <br />Chief Executive Officer's Signature <br />The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the <br />financial report will be completed and returned to the Gambling Control Board within 30 days of the date of our gambling <br />ac ti vi ry. <br />Chief executive officer's signature <br /> <br />Name (please print) 'T~)i~'j ~('~1C~ elf <br /> <br />Mail application and attachments <br /> <br /> Complete an application for each <br /> gambling activity: <br /> · one day of gambling activity <br /> · two or more consecutive days of <br /> gambling activity To: <br /> · each day a raffle drawing is held <br /> <br />Send: <br />· Ihe completed application, <br /> <br />Date <br /> <br />· a copy of your proof of nonprofit status (see instructions), and <br />· a $50 application fee. Make check payable to "State of Minnesota" <br /> <br />Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br /> <br /> <br />