Agenda - Council - 06/26/2007 - Laserfiche WebLink

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LG220 Application for Exempt Permit Page 2 of 2 4/07 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT If the gambling premises is within city limits, If the gambling premises is located in a township, both the city must sign this application. the county and township must sign this application. Check M the action that the city is taking on Check (') the action that the county is taking on this application. this application. k The application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. application is acknowledged with a 30 day waiting — The application is acknowledged with a 30 day waiting _The period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 days (60 days for a 1 st class city). days. The application is denied. The application is denied. Print name of city C— �: C=F� (Lc_ ` On behalf of the city, 1 acknowle ge this application. Signature of city personnelArceiving application (Title 1 2 bate ' 6 Signature of township official acknowledging application Title Date (CHIEF EXECUTIVE OFFICER'S SIGNATURE I The information provided in this application is complete and accurate to the best of my knowledge. l acknowledge that the financial report will be completed and returned to the Board within 30 days of the date of our gambling activity. Chiefexecutive officer's signature Name (please print) Date / / Complete an application for each gambing activity: Financial report and recordkeeping required • one day of gambling activity A financial report form and instructions will be sent with your • two or more consecutive days of gambling activity permit. Within 30 days of your date of activity the financial • each day a raffle drawing is held report form must be completed and returned to the Gambling Send with the completed application: Control Board. • a copy of your proof of nonprofit status, and Questions? • $50 application fee. Make check payable to Call the Licensing Section of the Gambling Control Board "State of Minnesota ". at 651- 639 -4076. To: Gambling Control Board If you use a TTY, call the Board by using the Minnesota Relay 1711 West County Road B, Suite 300 South Service and ask to place a call to 651 -639 -4000. Or, check ' Roseville, MN 55113 1 our web site at www.gcb.state.mn.us. Data privacy. This form will be made available in altemative format (i.e. large print, Braille) upon request The information requested on this form (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 information requested, the Board will be able to process your application. 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 Your name and and your organization's name and address will be public information when received by the Board. All the other information that you provide will be private data about you until the Board issues your permit. When the Board issues your permit, all of the information that you have provided to the Board in the process of applying for your permit will become public. If the Board does not issue you a permit, all the information you have provided in the process of applying for a permit remains private, with the exception of your name and your organization's name and address which will remain public. Private data about you are available only to the following: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent.