Laserfiche WebLink
LG220 Application f, qr Exempt, P, erm[t <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 taking on this application. <br /> <br /> T~e city approves the application with no <br />~l-.-~ait i n g period. <br /> <br />EThe city approves the application with a 30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city). <br /> <br />E]The city denies the application. <br />Print name of city ~/~75~Z <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 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 pedod. <br /> <br />DThe county the application with a 30 <br /> approves <br /> day <br /> waiting period, and allows the Board to issue a <br /> permit after 30 days. <br /> <br />D The counTM denies the application. <br /> <br />Print 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 /> <br />Pdnt name of township <br /> <br />Signature of township official acknowledging application <br /> <br />-RUe <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 />activity. <br />Chief executive officer's signature <br />Name (please print) ~//,¢./~ ~- 7'~F,.¢~// Date__/__/__ <br /> <br />Mail application and attachments <br /> <br /> Complete an application for each <br /> gambling activity: <br /> - one day ofgamblin§ activity <br /> o two or more consecutive days of <br /> §ambling activity <br /> · each day a raffle drawing is held <br /> <br />Send: <br />· the completed application, <br />· a copyofyour p~"oof of nonprofit status (see instructions), and <br />· a $50 application fee. Make check payable to"State of Minnesota". <br /> <br />To: <br /> <br />Gambling Control Board <br />17;I.1 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br /> <br />-65- <br /> <br /> <br />