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LG220 Application for Exempt Permit ��s Page 2 of 2 LOCAL UNIT OF GOVERNMENT ACKNOWLEDGMENT CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township The applicatfon is acknowledged with no waiting period. The application is acknowledged with no waiting period. The applfcation is acknowledged with a 30 day waiting The application is acknowledged with a 30 day walting period, and allows the Board to issue a permit after 30 days period, and aliows the Board to issue a permit after 30 [60 days for a lst class city]. days. The applicatlon is denied. The application is denied. Print city name Print county name Signature of clty personnel Signature of county personnel Title Date Title Date TOWNSHIP.If requfred by the county. 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, per Minnesota Statutes 349.166.] Print township name Signature of township officer Title Date CHIEF EXECUTIVE OFFICER'S SIGNATURE The information provided in this application is complete and accurate to the best of my knowledge. I ackn�wledge that the financial report wiil be completed and returned to the Board within 30 days of the event date. Chief executive officer's signature_��^-"'" `, v�Y`" Date ��D �� Printname �1��-� � �.� �.-� � �V^0� `f �" �YeSICJ�� REQUIREMENTS Complete a separate application for: Financial report and recordkeeping required • all gambling conducted on two or more cansecutive days, or A financial report form and instruct+ons will be sent with your • all gambling conducted on one day. permit,or use the online�il-in form available at Only one application is required if one or more raffle drawings www.gcb.state.mn.us. are conducted on the same day Within 30 days of the event date, complete and return Send application with: the�nancial report form to the GambUng Control Board. a copy of your proof of nonprofit status, and Questions7 _appifcation fee (non refundable). Make check payable to Call the Licensing Section of the Gambling Control Board "State of Minnesota." at 651-639-4000. To: Gambling Control Board This form wfll be made avaifable in akernafive format(i.e.large print,Braille) 1711 West County Road B, Suite 300 South upon requesc. Roseville, MN 55113 Data privacy notice: The Information requested on this All other informatlon provided will be pri- General; Commissloners of Administration, form(and any attachments)wlll be used by the Gambltng vate data about your organizatlon unUl the Minnesota Management&Budget, and Control Board(Board)to determine your organizatton's Board issues the perm)t. When the Board Revenue; Legislative Auditor,national and qualiflcations to be involved in lawful gambling activities in issues the permit,all Information provided Intematlonal gambling regulatory agencles; Minnesota. Your organization has the right to refuse to will become publlc, If the Board does not anyone pursuant to court order; other Indi- supply the Information; however, If your organization issue a permit,all information provided viduals and agencles speciffcally authorized refuses to suppiy this Information,the Board may not be remains private,with the exception of your by state or federal law to have access to abie to determine your organization's qualiflcations and, organization's name and address which wllt the Information; indivfduals and agencies as a consequence,may refuse to issue a permit. If your remain public. Private data about your for which law or legal order authorizes a organization supplies the Information requested,the Board organization are avaiiable to: Board mem- new use or sharing of information after thls wfil be able to process the applicatlon. Your organization's bers,Board staff whose work requires noUce was given; and anyone wlth your name and address will be public information when received access to the information; Minnesota's written consent. by the Board. Department of Pubiic Safety;Attorney