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Page 2 of 2 <br />LG220 Application for Exempt Permit 11/04 <br /> <br />Organization Name <br />Local Unit of Government Acknowledgment <br /> If the gambling promises Is within city limits, the <br /> city must sign this application. <br /> On behaif of the city, I acknowledge this application. <br /> <br /> Check the action that <br /> the city ia taking on .this application. <br />/ Th~e city approves the application with no <br /> iting period. <br /> <br />D The city approves the application with a 30 day <br /> waiting period, and allows the Board to issue a <br />IDpermit aRer 30 days (60 days for a first class <br /> city). <br /> <br /> The city denies the application. <br /> <br /> Signature of city personnel receiving application <br /> <br />If the gambling premises Is Iocat~l In a township, b~th <br />the county and township must sign thh, 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 />D The county approves the application with no <br /> waiting period. <br /> <br />D The 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 />D The county denies the application. <br /> <br />Prfnt name of county <br /> <br />Signature of county personnel receiving application <br /> <br />Date I / <br /> <br />TOW~ISHIP: On behalf of the township, I ac~flowledge that <br />tho o~ganinotion is applying for exempted gambling activity <br />wi~ifl the township IIm~. lA township 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 acknc,viedging application <br />Tiffs <br /> <br />Date / I <br /> <br />Chief Executive Officer's Signature <br />The informatton provided n this application is com~o~r~, accurate to the best of .m.y knowledge..I .a. ckn.o~vled.ge that th.e <br />financial report will be completed and retarfl~j~l~ the .Gambling Control Board wiffiin 30 days or me note ot our gamnung <br /> <br />Name (please print) <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 />· 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 />Gambll.ng Control Board <br /> 7tt West County Road B, Suite 300 South <br />Rosevllle, MN 55113 <br /> <br />-45- <br /> <br /> <br />