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<br /> <br />l <br /> <br />LG220 Application for Exempt Permit <br />LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT <br /> <br />Page 2 of 2 <br />2/07 <br /> <br /> <br />Your name and and your organization's name <br />and address will be public information when <br />received by the Board. All the other information <br />that you provide will be private data about you <br />until the Board issues your permit. When the <br />Board issues your permit, all of the information <br />that you have provided to the Board in the process <br />of applying for your permit will become public. If <br />the Board does not issue you a permit, all the <br />information you have provided in the process of <br />applying for a permit remains private, ~ ~ <br />exception of your name a~d yo~r orga.nlZa~on s <br />name and address which WIn remain public. Pnvate <br />data aboul ou are available onl to the followin : <br /> <br />If the gambling premises is within city limits, <br />the city must sign this application. <br /> <br />Check C..J) the action that the city is taking on <br />VthiS application. <br /> <br />6-. The application is acknowledged with no waiting period. <br /> <br />_The application is acknowledged with a 30 day waiting <br />period, and allows the Board to issue a permit after 30 <br />days (60 days for a 1st class city). <br /> <br />_The application is denied. <br /> <br />Print name of city t<. Cl m 5 e. . <br />On behalf of the city, I acknowledge thi application. <br />Signature of city personne~ application <br /> <br />D~ <br />TitleF~II~~~""'-+-Oate ~ Il;~ <br /> <br />Name (please print) <br /> <br />Complete an application for each gambing activity: <br />. one day of gambling activity <br />. two or more consecutive days of gambling activity <br />. each day a raffie drawing is held <br /> <br />Send with the completed application: <br />. a copy of your proof of nonprofit status, and <br />. $50 application fee. Make check payable to <br />"State of Minnesota". <br /> <br />To: Gambling Control Board <br />1711 West County Road B, Suite 300 South <br /> <br />Roseville, MN 55113 <br /> <br />Data privacy. This form will be made available in <br />altemative format (i.e. large print, Braille) upon <br />request. The information requested on this form <br />(and any attachments) will be used by the <br />Gambling Control Board (Board) to determine your <br />qualifications to be involved in lawful gambling <br />activities in Minnesota. You have the right to refuse <br />to supply the information requested; however, if <br />you refuse to supply this information, the Board <br />may not be able to determine your qualifications <br />and, as a consequence, may refuse to issue you <br />a permit. If you supply the information requested, <br />the Board will be able to process your application. <br /> <br />If the gambling premises is located i . . <br />the county and township must sign " ~ town~hlp~ both <br />thIS apphcation. <br />Check (..J) the action that the COU"ty. tak' <br />. t' "IS 109 on <br />this appllca Ion. <br /> <br />_The application is acknowledged With no waiting period. <br /> <br />-L- The. application is acknowledged .With a 30 day waiting <br />penod, and allows the Board to ISsue a permit after 30 <br />days. <br />_The application is denied. <br /> <br />Print name of county <br />On behalf of the county, I acknowledgethis application. <br />Signature of county personnel receiving application <br /> <br />~ <br /> <br />Title Date-1 I <br /> <br />TOWNSHIP: On behalf ofthe township, f acknowledge that the <br />organization is applying for exempted gall1bling activity within the <br />township limits. [A township has no statutory authority to approve <br />or deny an application (Minnesota Statute 349.213, subd. 2).J <br />Print name of township <br /> <br />~ <br /> <br />Signature of township official aCkn~dging application <br />itle Date -! <br /> <br />Date_2-_L3 I..QJ <br /> <br />Financi~1 report and reco.rdkee~ing required <br />A financial report form and Instructions Will be sent with your <br />permit. Within 30 days of your date of actiVity the financial <br />report form must be completed and returned to the Gambling <br />Control Board. <br /> <br />Questions? <br /> <br />Call the Licensing Section of the Gambling Control Board <br />at 651-639-4076. <br /> <br />If you use a 1lY, call the Board by using the Minnesota Relay <br />Service and ask to place a call to 651-639-4000 Or check <br />our web site at www.gcb.state.mn.us. ., <br /> <br />Bo~rd members,. staff of the Board whose work <br />~sslgn~en~ requfJ~s that they have access to the <br />Information, th~ MInnesota Department of Public <br />S~fety; the Mlnne.sota Attorney General; the <br />Minnesota CommisSioners of Administration, <br />Fina~ce, and. RevenUe; the Minnesota Legislative <br />AudItor, natlona! and international gambling <br />regulatory a~en~~s; anyone pursuant to court <br />order; other IndlVlduqls and agencies that are <br />specifically aulhoriz~ by state or federal law to <br />have ~ccess to.the Information; individuals and <br />agenCies for which !a"" or legal order authorizes <br />a n~w use ~r Shanng of information after this <br />Notice was Iven; and an one with our consent. <br /> <br /> <br />-25- <br />