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LG220 Application for Exempt;Permit <br /> <br />Organization Name <br />Local Unit of Government Acknowledgment <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 app!icati°n. <br /> <br />[ The city approves the application;with no : <br /> waiting period. <br /> <br />BThe city approves the application with a 30 day <br />waiting period, and allows the $o$~'d 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~e <br />Signature of city personnel receiving applica{ion, <br />Title r:- ' ,,--,c.~_c~-~. ~ ,' <br /> <br />Page 2 of 2 <br /> 11/04 <br /> <br />ilf the gambling premises is located in a township, both <br />the county and township must sign this application. <br /> <br />iOn 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 />iF-] The county denies the application. <br /> <br />Print name of county <br /> <br />Signature of county personnel receiving application <br />'RUe <br /> <br />Date / t <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 />~tle <br /> <br />Date / / <br /> <br />Chief Executive Officer's Signature ~ ' <br />The information provided in this application ils complete~ccurate to the best of my knowledge. I acknowledge that the <br />financial report will be completed and retu~he Ga~:foling Control Board within 30 days of the date of our gambling <br />activity. "*'~L~'~//~ /'~2_ _ <br />Chief executive oficer's %ture (~~~~ <br />Name (please print)',~ 0 ~"~ ,r i~,~_.,~I /_~' q"~ ~'2 /~ Date <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 />Send: <br />· th~ 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 /> 17.11 West County Road B, Suite 300 South <br /> Roseville, MN 55113 <br /> <br /> <br />