Laserfiche WebLink
• <br />• <br />Page 2 :of 2 <br />LG220 Application for Exempt Permit 2106 <br />Organization Name <br />Local Unit of Government Acknowledgment <br />If the gambling premises is within city limits, the <br />city must sign this application. <br />On behalf of the city, I acknowledge this .application. <br />Check the action that <br />the city is taking on this application. <br />M The city approves the application with no <br />waiting period. <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 daysIor a first class <br />city). <br />The city denies the applicatian, <br />Print name of city �` �� ��► <br />Signature of city personnel receiving application <br />Title o�• `Z— <br />Date <br />If the gambling premises is located in a township, both <br />the county and township mustsign this application. <br />On behalf of the county I acknowledge this application: <br />Check the action that <br />the county is. taking on this application. <br />The county approves the application with no <br />waiting period: <br />The county approves the application with a 3G day <br />waiting period, and allows the Board to issue a <br />permit after days, <br />The county denies the application. <br />name of county <br />Signature of county personnel receiving application <br />Date I <br />TOYtWNSHIP. On behalf of the township,_ I acknowledge that <br />the organization is applying for exempted gambling activity <br />WItthin the township limits. [Atownsfiip has.no statutory <br />authority approve of deny an application <br />(Minnesota Statute 349:21:3, subd. 2):] <br />Print name of township <br />Signature of township:official acknowledging application <br />Title <br />Date ! / <br />Chief Executive Officer's Signature <br />The information provided in this.application is complete and accurate to the best of my knowledge. I acknowledge that <br />the. financial report will be completed and retur he Gambling Control Boa within 30 days of the date of our <br />gambling activity. <br />Chief executive officer's signature <br />Name (please print} �1(0� �v �' �Say Date��/ /o I e2 7 <br />Mail Application and Attachments <br />Complete an application for each Send <br />• gambing activity: • the completed application, <br />• one day of gambling activity • a copy of your proof of nonprofit status, and <br />two or more consecutive days of ' a $50 application fee. Make check. payable to "State of Minnesota'). <br />gambling activity <br />• each day a raffle drawing is held To: Gambling Control Board <br />1711 West County. Road B, Suite 300 South <br />Roseville, MN 55113 <br />15- <br />