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Page 2 of 2 <br />2/06 <br />LG220 Application for Exempt Permit <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 days for a first class <br />city). <br />The city denies the application. <br />Print name of city C °� 9C <br />Signature of city personnel receiving application <br />Title <br />Date <br />Chief Executive Officer's Signature <br />The information provided in this application is comp) <br />the financial report will be completed a tume. to <br />gambling activity. ` I/-,-- <br />.-j <br />if If the gambling premises is located in a township, both <br />the county and township must sign this application. <br />On behalf of the county, I acknowledge this application. <br />Check the action that Ircation. <br />the county is taking on this app <br />The county approves the application with no <br />waiting period. <br />0 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 />The county denies the application. <br />Print name of county <br />Signature of county personnel receiving application <br />Date <br />TOWNSHIP: On behalf of the township,) acknowledge that <br />the organization is applying 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 />Print name of township <br />Signature of township official acknowledging application <br />Title <br />Date — <br />accurate to the best of my knowledge. I acknowledge that <br />nblincl Control Board within 30 days of the date of our <br />Chief executive officer's sig Date �' <br />Name (please print) 4. 6; u L 2 <br />Application and Attachments <br />t — <br />Fore i <br />Send <br />application for each . the completed application, <br />vity: • a copy of your proof of nonprofit status, and <br />of gambling activity . a $50 application fee. Make check payable to "State of Minnesota'7. <br />ore consecutive days of <br />ng activity T Gambling Control Board <br />ay a raffle drawing is held 1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />—23— <br />