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<br />l <br /> <br />. <br /> <br />. <br /> <br />LG220 Application for Exempt Permit <br /> <br />Organization Name <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 />Page 2 of 2 <br />12/03 <br /> <br />CReek the action that <br />the city is taking on this application. <br /> <br />~e city approves the application with no <br />~ waiting period. <br /> <br />'0 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 /> <br />ntle <br /> <br />r=;'~ <br /> <br />dT;~ <br /> <br />oate-.lJ~~ <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 />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 />D The county denies the application. <br /> <br />Print name of county <br /> <br />(Signature of county personnel receiving application) <br />ntle <br />Oate-1----1_ <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).J <br /> <br />Print name of township , <br /> <br />(Signature of township official acknowledging application) <br />ntle <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. <br /> <br />Name (please print) <br /> <br />Mail Application and Attachments <br /> <br />At least 45 days prior to your scheduled activity date 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 />Application fees are not prorated, refundable, or transferable. <br /> <br />Send to: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br /> <br />Chief executive officer's signature <br /> <br />Date <br /> <br />I_I <br /> <br />If your application has not <br />been acknowledged by the <br />local unit of govemment or <br />has been denied, do not <br />send the ,applicatiol)to the <br />Gambling Control Board. <br /> <br />-127- <br />