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Page 2 of 2 <br /> <br />LG220 Application for Exempt Permit <br />Organization Name A ~ ¢..'~_.~,. I~ ~o¢3'~%~-~. <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises is within city limits, the <br />city must sign t~tis 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 /> "~he city approves the application with no <br /> ~,~"~vaiting pedod. <br /> <br />']The 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 />D The city denies the application. . <br /> <br />Signature of c~ty 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 />D The county approves the application with no <br /> waiting period. <br /> <br />D The county approves the application with a 30 da <br /> waiting period, and allows the Board to issue a <br /> permit after 30 days. <br /> <br />] The county denies the application. <br /> <br />Pdnt name of county <br /> <br />Signature of county personnel receiving application <br />T~tle <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 limito, IA township 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 />Signature of township official acknowledging application <br />T~tle <br /> <br />Date / / <br /> <br />Chief Execut've Officer's Signatdre//J <br />The information provided in this appian i~c.~j~eyand accurate to the best of my knowtedge. I acknowledge that the <br />financial report will be sompleted a~ ~e Gambling Control Board within 30 days of the date of our gambling <br />activity. '--.~/...% / ~' . <br />Chief executive officer's signature [ ;/ /~"~v" '- <br />Name (please pdn,) "~/,~.- , ,L.! J~"/l ~ Date c2 / ,~ , ~-'(~ <br /> <br />Mail application and attachments <br /> <br /> Complete an application for each <br /> gambling activity: <br /> · one day of gambting activity <br /> · two or more cansecutive 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 />Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br /> <br />-135- <br /> <br /> <br />