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LG220 Application for Exempt Permit. ~ <br />Organ za on Neme <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 />~wwa e city approves the application with no <br /> iting period. <br /> <br />D The city approves the application with a 30 day <br /> waiting pedod, and allows the Board to issue a <br /> permit after 30 days (60 days for a first cJass <br /> city). <br /> <br /> D The city denies the application. <br /> <br /> Pdnt name of city <br /> <br /> Signature of city personnel receiving a~plimtion <br /> <br />Date <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 />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 pedod, and allows the Board to issue a <br /> permit after 30 days. <br /> <br />D The county denies the application. <br /> <br />Pdnt name of county <br /> <br />Signature of county pemonnel receMng application <br />TPde <br /> <br />Date / 1__ <br /> <br />TOWNSHIP: On behalf of the township, I acknowledge that <br />the organization is a pplying 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 />Pdnt 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 c~m.-p~te~anCi'~ib-~7~{e ta~t of my knowledge. [ acknowledge that the <br />financial reper~ will be completed and retu~d'-~Ythe Gambling C~ within 30.d~ys of the date of our gambling <br />e~,v,ty. /'( ~--- · - -/.-t:~-' <br />Chief executive officer's signet~r~ ~../1. ,111'._ <br />Name <please pdnt) ~/~' 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 />· thecomp[eted application, <br />· a copy of your proof of non profit 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 />-41- <br /> <br /> <br />