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Application for Exempt Permit- LG220 <br />Organization Name <br /> <br />Page 2 qf 2 <br /> 8/00 <br /> <br />Local Unit of Government Acknowledgment <br /> If the gambling premises is within city limitS, the <br /> cl~ must sign this application. <br /> <br />On behalf of the city, I acknowledge this application. <br /> <br /> Check the action that <br /> the city is taking on this application. <br /> <br /> Twhe city approves the application with no <br /> airing period. <br /> <br />DThe city approves the application with a 30 day <br />waiting pedod, and allows the Board to issue a <br />permit after 30 days (60 days for a first class <br />city). <br /> <br />DThe city denies the applicaUorr. ~ <br /> <br />(Signature of city personnel receMng application) <br />Title_ (~' r'~:,..~c~ ¢--.-~, ~ <br /> <br />Date / / 0 _.~ <br /> <br />llf 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.acknowle~ge this application. <br /> <br /> · Check the acti°n that <br /> the. county is taking on ·this application. <br /> <br />D The county approves the application with no <br /> . waiting period. <br /> <br />DThe county approves the application With a30 day <br />waiting period, and allows the Board to issue a <br />permit after 30 days. <br /> <br />r~. The county denies the application. <br /> <br />Pr{nt name of county <br /> <br />(Signature of county personnel mceMng applicatbn) <br />T'~le ' <br />Date ,. / /.~ <br /> <br />TOWNSHIP: On behalf of the township, I acknowledge that' <br />the organization is appyng for exempted gambl{ng activity <br />within ~e township limits. IA township has no statutory <br />authority to approve or deny an application (Minn. Stab sec. <br />349~13, subd. 2).] <br />Print name of township <br /> <br />(Signature of township official acknowledging application) <br />'r'~e. <br /> <br />Date / /.__ <br /> <br />Chief Executive Officer's Signature <br />The Information provided in this application is complete and accurate to the best of my knowledge. <br /> <br />Chief executive ofrmer's signature <br /> <br />Name (please print). Date L__I , <br /> <br />Mail Application and Attachments <br />At least 45 days prior to your scheduled activity date send: · the completed application, <br /> · a copy ofyour proof of nonprofit status, and <br /> · a $25 applicatbn fee (make check payable to "State of Minnesota"). <br /> Application fees are not prorated, refundable, or transferable. <br /> <br /> Send to: Gambling Control Board <br /> 1711 West County Road B, Suite 300 South <br /> Roseville, MN 55113 <br /> <br />If your appl{cation has not <br />been acknowledged bythe <br />local unit of government or <br />has been denied, do not <br />send the application to the <br />Gaming Control Board. <br /> <br />-103- <br /> <br /> <br />