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<br />L(;:22o Application 1<Ir Exempt Permit r1: <br />Organization Name_~Jl I,....j / +i <br />Local Unit of Government Acknowledgment <br /> <br />If the gambling premises b~within city limits. the <br />city must sign this application. <br />0" behalf of lh~ ci~. I acknowledge.this application.. <br /> <br />From: 6516394034 <br /> <br />Check the .action that <br />the city is taking on this application. <br /> <br />O The city approves the appli~tion with no <br />waiting period. <br /> <br />:0 The city approves the application with a .30 day <br />waiting period, and allows the Soard to Issue a <br />permIt after 30 days (60 deWs for a first class <br />city). . <br /> <br />o The city denies the application. <br /> <br />-~cldly C\;r~ · {- ~/j>"U} <br /> <br /> <br />.Signature of city-personnel receMng.application <br /> <br />l1tJe <br /> <br />F",-r, ~ <br /> <br />c:5-i-t ~ <br /> <br />Date 7'/ ~9 0 ~ <br /> <br />Page: 3/8 <br /> <br />Date: 5/16/2006 1:36:16 PM <br /> <br />Page 2 of 2 <br />2/06 <br /> <br />. <br /> <br />-------- <br /> <br />,ff the. gambling premises is located In a townshJp,. both <br />the county. and townShip must sign thi$ apPlication. <br /> <br />On behalf of .the county, 1 acknowledge this application. <br /> <br />.Check the actIon that <br />the County'is taking on thIs application. <br /> <br />o The courrty aPProves the application with no <br />waiting period. . <br /> <br />o The county approves the application with a 30 day <br />waiting period, and aUows the Board to issue ,8 <br />permit after 30 days. <br /> <br />o The county denies' the application. <br /> <br />Prlnt name of counw <br /> <br />Signature of county personnel rece/vJng appJlcatlon <br />TItle <br />Date---l---1_ <br /> <br />'TOWNSHIP: On behalf of the township. I aCknowledge that <br />the organization is applying for .exempted gambling activity <br />wltliin the township limits. [A township has no'statutoJy' <br />authority to apPtr;lve or deny an application <br />(Minnesota statute 34S.213. subd. .2)J <br /> <br />. Print name of township <br /> <br />. <br /> <br />Signature of township oft/olaf acknoWJedging application <br />Title <br />Date----.l---l_ <br /> <br />Chief Executive ,Officer's 'Signature ( <br /> <br />The information provided in ,this application is'complete end accurate.to the 1;lest,of my knoWledge. J acknowledge that <br />the financial report WIll be completed and 'retumed:to the mbling Control Board within 30 days of the date of our <br />gambling activity. <br /> <br />Chief executive omcer'ssignalure <br />Name (please print) . f4.e ," iJ.. " <br /> <br /> <br />Mail Application and Attachments <br /> <br />Complete an application for each <br />gambing activiW- <br />. one day of gambling actiYij;y <br />. two or more consecutlve days of <br />gambling activi!y <br />. each day a raffle drawing is held <br /> <br />.Dats.!:':l.L1.:i.; 'I) b <br /> <br />Send <br />. the completed application, <br />. a copy of your proof of nonprofit status. and <br />. .01 $50 application fee. Make check payable to "Stale of Minnesota"), <br /> <br />To: Gambling Control Board <br />1711 West County..Read 'S, SLlite300 South <br />Rosevllle. MN S5113 <br /> <br />:: <br /> <br />. <br /> <br />-136- <br /> <br />This fax was received by GFI FAXmaker fax.server. For more information, visit http://www.gfi.com <br />