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LG220 Application for Exempt Permit <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 />On behalf of the city, I acknowledge this aPpliCation. <br /> <br /> Check the action that <br /> the city is taking on this application. <br /> With <br />Thecity approves application no <br /> the <br /> waiting 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 />Print name of city ~_.~~~C_-t <br /> <br />Signature of city personnel receiving application <br /> <br />Page 2 of 2 <br /> 11/04 <br /> <br />If the gambling premises is located in a township, both <br />the county and township must signthis 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 />P'rint 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 />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 /> <br />activity. <br />Chief executive officer's signature <br /> <br />Name (please print) N .0~.~¢-*'¢ <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 <br /> · each day a raffle drawing is held <br /> <br />Date ~ /_.~/ / 42 ~ <br /> <br />Send: <br />· the comPleted application, <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 />To: Gambling Control Board <br /> 1711 West County Road B, Suite 300 South <br /> Roseville, MN 55113 <br /> <br /> <br />