5F, Approve Resolution 2012-016 for Charitable Gambling License for the Lady Slipper Chapter of the ABWA to Conduct Charitable Gambling at Flaherty's Bowl

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LG214 Premises Permit Application 3/11 Page 2 of 2 Acknowledgment by Local Unit of Government: Approval by Resolution CITYAPPROVAL COUNTYAPPROVAL for a gambling premises for a gambling premises located within city limits located in a township City name County name Date approved by city Date approved by county Resolution number if any Resolution number if any Signature of city personnel Signature of county personnel Title Date / / Title Date t ! Acknowledgment and Oath 1. 1 hereby consent that local law enforcement officers, 5. 1 am the chief executive officer of the organization. the Board or its agents, and the commissioners of 6. 1 assume full responsibility for the fair and lawful operation of revenue or public safety and their agents may enter all activities to be conducted. and inspect the premises. 7. 1 will familiarize myself with the laws of Minnesota governing 2. The Board and its agents, and the commissioners lawful gambling and rules of the Board and agree, if licensed, of revenue and public safety and their agents are to abide by those laws and rules, including amendments to authorized to inspect the bank records of the gambling them. account whenever necessary to fulfill requirements g. Any changes in application information will be submitted to of current gambling rules and law. the Board no later than 10 days after the change has taken 3. 1 have read this application and all information effect. submitted to the Board is true, accurate, and g. 1 understand that failure to provide required information or complete. providing false or misleading information may result in the 4. All required inform n ha een fully disclosed. denial or revocation of the license. Sig ature of Chle Executive Officer(designee may not sign) Date Print name Reset Form Print form and have CEO sign Data privacy notice: The information requested Your organization's name and Private data about your organization are on this form(and any attachments)will be used address will be public available to: Board members,Board staff by the Gambling Control Board(Board)to information when received by whose work requires access to the information; determine your organization's qualifications to the Board. All other information Minnesota's Department of Public Safety; be involved in lawful gambling activities in provided will be private data Attorney General;Commissioners of Minnesota. Your organization has the right to about your organization until the Administration, Minnesota Management& refuse to supply the information;however,if Board issues the permit. When Budget,and Revenue;Legislative Auditor, your organization refuses to supply this the Board issues the permit,all national and international gambling regulatory information,the Board may not be able to information provided will agencies.anyone pursuant to court order;other determine your organization's qualifications become public. If the Board individuals and agencies specifically authorized and,as a consequence,may refuse to issue a does not issue a permit,all by state or federal law to have access to the permit. If your organization supplies the information provided remains information;individuals and agencies for which information requested,the Board will be able to private,with the exception of law or legal order authorizes a new use or process your organization's application. your organization's name and sharing of information after this notice was address which will remain public. given;and anyone with your written consent. This form will be made available in alternative format (i.e, large print, Braille) upon request.