Agenda - Council - 03/13/2007 - Laserfiche WebLink

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Page 2 of 2 2/07 LG220 Application for Exempt Permit LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, the city must sign this application. Check (..J) the action that the city is taking on , this application. --,The application is acknowledged with no waiting period, _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a 1st class city). _The application is denied. Print name of city C:~+-~ * ~M On behalf of the city, I acknoWledge this application. Signature of cit}t personne!flceivi~g application dl),... "'- ~ Titler:::.~NO.,.",,<;..,-- ~'\:oI" Date~ r ~ If the gambling premises is located in a township, both the county and township must sign this application. Check (..J) the action that the county is taking on this application. _The application is acknowledged with no waiting period. _The application is acknowledged with a 30 day waiting period, and allows the Board to issue a permit after 30 days. _The application is denied. Print name of county On behalf of the county, I acknowledge this application. Signature of county personnel receiving application Title Date / TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying for exempted gambling activity within the township limits. [A township has no statutory authority to approve or deny an application (Minnesota Statute 349.213, subd. 2).] ..' Print name of township Signature of township official acknowledging application Title Date CHIEF%EXECOTIVEtOFF1CER~.SSIGNATURE; Name (please print) Complete an application for each gambing activity: . one day of gambling activity . two or more consecutive days of gambling activity . each day a raffle drawing is held Send with the completed application: . a copy of your proof of nonprofit status, and . $50 application fee. Make check payable to "State of Minnesota", '_..--:.'-..':-."':<....:::-.:-',-<::... Date~_~..:lJ-.CL} Financial report and record keeping required A financial report fonn and instructions will be sent with your pennit. Within 30 days of your date of activity the financial report form must be completed and returned to the Gambling Control Board, Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4076. To: Gambling Control Board 1711 West County Road 8, Suite 300 South Roseville, MN 55113 Data privacy. This form wUl be made available in altemative format (Le. large print, Braille) upon request The information requested on this fonn (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and. as a consequence, may refuse to issue you a permit If you supply the infonnation requested. the Board will be able to process your application. If you use a TTY, call the Board by using the Minnesota Relay Service and ask to place a call to 651-639-4000, Or, check our web site at www.gcb.state.mn.us. Your name and and your organization's name Board members, staff of the Board whose work and address will be public infonnation when assignment requires that they have access to the received by the Board. All the other information information; the Minnesota Department of Public that you provide will be private data about you Safety; the Minnesota Attorney General; the until the Board issues your permit. When the Minnesota Commissioners of Administration, Board issues your permit. all of the information Rnance, and Revenue; the Minnesota Legislative that you have provided to the Board in the process Auditor, national and international gambling of applying for your permit will become pubfic. If regulatory agencies; anyone pursuant to court the Board does not issue you a permit, all the order; other individuals and agencies that are information you have provided in the process of specifically authorized by state or federal law to applying for a permit remains private. with the have access to the information; individuals and exception of your name and your organization's agendes for which law or legal order authorizes name and address which will remain public. Private a new use or sharing of information after this data about OU are available onl to the followin: Notice was iven; and an one with our consent -29-