Agenda - Council - 11/13/2007 - Laserfiche WebLink

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LG220 Application for Exempt Permit LOCAL UNIT OF GOVERNMENT ACKNOW LEDGMENT 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 ('~) the action that the city is taking on Check ('~) the action that the county is taking on this application. this application. ,The application is acknowledged with no waiting period. _The application is acknowledged with no waiting period. The application is acknowledged with a 30 day waiting The application is acknowledged with a 30 day waiting _ period, and allows the Board to issue a permit after 30 period, and allows the Board to issue a permit after 30 days (ti0 days fora 1st class city). days. The application is denied. The application ~is denied. _ 'F 12c,~r~ t ~ : ~-.~ cam Print city name Print county name , , ,, . ~ On behalf of the county, l acknowledge this application. On behalf of the city, I acknowledge this application. Signature of county personnel receiving application Signature of city personne receiving application ~-•-•~ Title Date ! / Title-~..n.~~~ t~Date ~. t / ZL~ TOWNSHIP: On behalfofthetownship,/acknowledgethatthe 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 township name Signature of township official acknowledging application Title Date / / CHIEF EXECUTIVE OFFICER'S SIGNATUR E The information provided in this application, incomplete and accurate to the best of my knowledge. 1 acknowledge that the date of our gambling acfivity. fhe financial report will be completed and retu d Board within 30 da fo f h e y - - ( ~ Chiefexecutiveofficer'ssignature GL~-~ G1'-/~ ~ Date/ ~ ~ /~ Complete an application for each gambing activity: ~ f ~ Financial report and recordkeeping • one day of gambling activity `/ required • two or more consecutive days of gambling acfivity ~ A financial report form and instructions will be • each day a raffle. drawing is held sent with your permit. Within 30 days of the Send application with: activity date, complete and return the financial • a copy of your proof of nonprofit status, and report form to the Gambling Control Board.. • $50 application fee for each event. Questions? Make check payable to "State of Minnesota." Call the Licensing Section of the Gambling To: Gambling Control Board Control Board at 651-639-4076. 1711 West County Road B, Suite 300 South Roseville, MN 55113 Data privacy. This form will be made available the Board will be able to process your Board staff whose work requires access to in alternative format (.e, large print, Braille) upon application. Your name and and. your the information; Minnesota's Department of request The information requested on this organization's name and address will be public Public Safeiy; Attorney General; Commissioners form {and any attachments) will be used by the information when received by the Board. All of Administration, Fnance, and Revenue;. Gambling Control Board (Board) to determine the other information you provide. will be private Legislative Auditor, national and international your qualifications to be involved in lawful data until the Board issues your permit When gambling regulatory agencies; anyone pursuant gambling activities in Minnesota. You have the the Board issuesyour permit, all of the to court order, other individuals and agencies right to refuse to. supply the information information provided to the Board will become that are specifically authorized by state or requested; however, if you refuse to supply public. If the Board does not issue a permit, all federal law to have access to the information; this information, the Board may not be able to information provided remains private, with the individuals and agencies for which law or legal determine your qualfcations ahd, as a exception of your name and your organization's order authorizes a new use or sharing of consequence, may refuse to issue you a name and address which will remain public. information after this Notice was given; and permit If you supply the information requested, Private data are available to: Board members, anyone with your consent .~ -29- Page 2 of 2 6/07