CCP 04-10-2007 - Laserfiche WebLink

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LG220 A lication for Exem t Permit Page 2 of 2 pp p ~/os Organization Name St. John the Baptist Catholic Church ~ . Local Unit of Government Acknowledgment If the gambling premises is within city limits, the city must sign this application. On behalf of the city, I acknowledge this application. Check the action that the city is taking on this application. ® The city approves the application with no waiting period. ^ The city approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days (60 days for a first class city). The city denies the application. Print name of ci ~~ '~-~~ n Signature of cit a noel receiving application Title t/ ~ Date/_~/~_ If the gambling premises is located in a township, both the county and township must sign this application. On behalf of the county, I acknowledge this application. Check the action that the county Is taking on this application. The county approves the application with no waiting period. _ The county approves the application with a 30 day waiting period, and allows the Board to issue a permit after 30 days. The county denies the application. Print name of county Signature of county personnel receiving application Title Date / / TOWNSHIP: On behalf of the township, I acknowledge that the organization is applying forexempted gambling activity within the township limits. [Atownship has no statutory authority to approve or deny an application (Minnesota Statute 349213, subd. 2).] Print name of township Signature of township official acknowledging application Date / / Chief Executive Officer's Signature The information provided in this application is complete and accurate to the best of my knowledge. I acknowledge that the financial report will be completed and returned to the mb ' ontrol Board wi in 30 days of the date of our gambling activity. ,~ /f /J ~~ /~ Chief executive officer's Name (please print) (Rev.) Michael. Skluzacek - ~ Date 4 / 2 / 2007 Mail Application and Attachments Complete an application for each Send gambing activity: the completed application, • one day of gambling activity a copy of your proof of nonprofit status, and • two or mare consecutive days of a $50 application fee. Make check payable to "State of Minnesota"). gambling activity To: Gambling Control Board • each day a raffle drawing is held 1711 West County Road B, Suite 3U0 South Roseville, MN 65113