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<br />. <br /> <br />. <br /> <br />. <br /> <br />LG220 Application for Exempt Permit .1 <br />Organization Name____J 1\'::> b:, . Co "'.... ..,.. )' <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 c[!y, I acknowledge this application. <br /> <br />Check the action that <br />the city is taking on this application. <br /> <br />f\7I The city approves the application with no <br />Lf'" waiting period. . <br /> <br />O 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 />o The city denies the application. <br /> <br /> <br />Signature of city personnel receiving application <br />litle 'F~ ~u-. <Yo;"': ~ <br /> <br />Oate~/j 01 C\o <br /> <br />I~. ~.re;...J. f '~'" v.e.- <br /> <br />Page 2 of 2 <br />2/06 <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 ofthe county, I acknowledge this application. <br /> <br />Check the action that <br />the county is taking on this application. <br /> <br />O The county approves the application with no <br />waiting period. - <br /> <br />o 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 />o The county denies the application. <br /> <br />Print name of county <br /> <br />Signature of county personnel receiving application <br />litle <br />Oate_I_I_ <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. [A township has no statutory <br />authority to approve or deny an application <br />(Minnesota Statute 349.213, subd. 2).] <br /> <br />Print name of township <br /> <br />Signature of township official acknowledging application <br />litle <br />Oate_/~/__ <br /> <br />Chief Executive Officer's Signature <br /> <br />The information provided in this application is complete and accurate to the best of my kn'owledge. I acknowledge that <br />the financial report will be completed and returned to the GamblingControl Board within 30 days of the date of our <br />gambling activity. <br /> <br />Chief executive officer's signature <br />Name (please print) (). ",.t!/ s-,i 4"'" ~ ~ 4~" <br /> <br />Date_O-.b__/ J.~.JJ;? ~_ <br /> <br />Mail Application and Attachments <br />Send <br />the completed application, <br />. a copy of your proof of nonprofit status, and <br />. a $50 application fee. Make check payable to "State of Minnesota"). <br /> <br />Complete an application for each <br />gambing 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 />To: <br /> <br />Gambling Control Board <br />1711 West County Road S, Suite 300 South <br />Roseville, MN 55113 <br /> <br />-123- <br />