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r <br />B5/07/2003 14:09 6516985203 GRAVXSTIMSO PAGE 07 <br />tiilf fStfiUiiWifiiatif ‘^ 7 <br />LO220 <br />Oiganbaton Namt. <br />Local Unit of Gowmm^nt Acknewtedoment <br />If tha gambling pramisas Is within city limKa, tha <br />city must sign this appUcabon.______ <br />On bahalf of the city. I acknowledga thb apprcation. <br />Check tha action that <br />tha cHy Is taking on this appllcatton. <br />PI The city approves the appfieation with no <br />LJ waiting period <br />PI The city approves the application with a 30 day <br />LJ waiting period, and allows the Board to issua a <br />perms after 30 days (60 days fbr a first class <br />city). <br />Q The cl^ denies the appfieation. <br />Print name of cSy. <br />(SIgnatuia of dly personnal lacaMng appicalton) <br />TWe________ <br />Data.I <br />If the gambling premises Is located in a township, both <br />tha counbrand township must s'an this application. <br />On behalf of the counbr. I acknowledge this appfieation <br />Check tha action that <br />the county is taldng on this application. <br />PI The county approves the application with no <br />U waiting period. <br />n The county approves the application wSh a 30 day <br />wafting period, and allows the Board to issue a <br />permit after 30 days. <br />Q The counfy denies the application. <br />Print name of county <br />(Signature of county personnel raeoMng appfcalfan) <br />TWO____________ <br />Date./_7 <br />TOWNSHIP: On behaV of tha township. I acknowtodgoftiat <br />the ergankai^n is applying for exempted gambing actMly <br />wWiln tha township fmits. [A township has no statutory <br />authority to approve or deny an application (Minn. Stat sec. <br />349.213, subd. 2).] <br />Print name of township <br />(Signature of township official acknowledging appication) <br />TWe_ <br />Date.// <br />Chief Executiva Officer’s Signature <br />The information provided In this application is complete and accurate to the best of my knowledge. <br />Chief exBCUtiuB oflicer's signature. <br />Name (please print).Date. <br />Mail Application and Attachments <br />At least 4S days prior to your scheduled activity date send; <br />• the completed application, <br />• a copy of your proof of nonprofit status, and <br />• a S2S application fee (make check payable to “State of Minnesota"). <br />Application fees are not prorated, retlindable, or transferable. <br />Sand to:Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roeeville, MN M113 <br />If your appfieation has not <br />been acknowledged by the <br />local unit of govsmmant or <br />has been denied, do not <br />send the appka^ to the <br />Gambling ConM Board. <br />i <br />!