Book # 74 3-12-96-7-9-96, 96-055- 96-150

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• Local Unit of Government Jurisdiction this gambling premises located within city limits? ® Yes 0 No lip If Yes, write the name of the City: City Name New Brighton If No, write the name of the County and the Township: County Name Township Name Check the appropriate status of the Township: Dorganized [Jinorganized [reincorporated Local Unit Of Government Acknowledgment 1. The city must sign this application if the gambling 3. DO NOT submit this application to the Gambling Control premises is within city limits. Board if it is denied by the local unit of government. 2. The county and township must sign this applica- 4. NOTE: A Township may not deny an application. tion if the gambling premises is not within city limits. Upon submission of this application to the Gambling Control Board, the exemption will be issued not more than 30 days (60 days for cities of the 1st class) from the date the local unit of government signed the application, provided the application is complete and all necessary information has been received, unless the local unit of government passes a resolution to specifically prohibit-the activity. A copy of that resolution must be received by the Gambling Control Board within 30 days of the date filled in below. Cities of the first class have 60 days in which to disallow the activity. City or County Acknowledgment of Receipt of Township Acknowledgment of Awareness of Application Application glignature of person receiving application Signature of person acknowledging application Date R ceived: 6-/a -9' Date Signed: Title ofson receiving application Title of person acknowledging application Oath of Chief Executive Officer I ir 400• - - -• is application and all information is true, accurate and complete. Date: 41Z Pen g a resident 6/7/96 Submit the application at least 45 days prior to your scheduled date of activity. Be sure to attach the $25 application fee and a copy of your proof of nonprofit status. Mail the complete application and attachments to: Gambling Control Board 1711 W. County Rd B Suite 300S Roseville, MN 55113 This publication will be made available in alternative format (i.e. large print, braille) upon request. Questions on this form should be directed to the Licensing Section of the Gambling Control Board at (612)639-4000. 0 Hearing impaired individuals using a TDD may call the Minnesota Relay Service at 1-800-627-3529 in the Greater Minnesota Area or 297-5353 in the Metro Area. The information requested on this form will be used by the Gambling Control Board (GCB)to determine your compliance with Minnesota Statues and rules governing lawful gambling activities. All of the information that you supply on this form will become public information when received by the GCB.