CCP 05-29-2001 - Laserfiche WebLink

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Acknowledgment Grp 2'Z Page of Gambling Site Authorization Oath 6. any changes in application information I hereby consent that local law enforcement I declare that: will be submitted to the board and local officers,the board or agents of the board,or 1. I have read this application and all unit of government within ten da s of the commissioner of revenue or y information submitted to the board is true, the change;and public safety or agents of the commissioners, accurate, and complete; 7. I understand that failure to provide may enter the premises to enforce the law. 2. all otheruired information has been � frequired information or providing false or Bank Records Information fully disclosed; misleading information may result in the The board is authorized to inspect the bank 3. I am the chief executive officer of the denial or revocation of the license. records of the gambling account whenever organization; necessary to fulfill requirements of current 4. I assume full responsibility for the fair and gambling rules and law. lawfiil operation of all activities to be Organization License Authorization conducted; I hereby authorize the Gambling Control g, 1 will familiarize myself with the laws of Signature4f e chief executive Board to modify the class of organization Minnesota governing lawful gambling and officer(Designee may not sign) license to be consistent with the class of rules of the board and agree,if licensed,to permit being applied for. abide by those laws and rules,including �'• �(/ O� amendments to them; elate Local Unit of Government Acknowled ment and Algjgroval On behalf of the city,I hereby acknowledge this application C) for lawful gambling activity at the premises located within Print&nofity the city's jurisdiction,and that a resolution specifically approving or denying the application will be forwarded to � the applying organization. Si afore of city per receiving application � Title Date For the township;On behalf of the township,I acknowledge that the organization is applying to conduct lawfiil gambling Print name of township activity within the township limits. A township has no statutory authority to approve or deny an Signature of township official receiving application application(Minn.Stat.sec.349.213,subd.2). Title Date For the county:On behalf of the county,I hereby acknowledge this application for lawful gambling activity at Print name of county the premises located within the county's jurisdiction,and that a resolution specifically approving or denying the application will be forwarded to the applying organization. Signature of county personnel receiving application / / Title Date The information requested on this form(and Your name and address will be public Board whose work assignment requires that any attachments)will be used by the Gambling information when received by the Board. All they have access to the information;the Control Board(Board)to determine your the other information that you provide will be Minnesota Departrnent of Public Safety;the qualifications to be involved in lawful gambling private data about you until the Board issues Minnesota Attorney General;the Minnesota activities in Minnesota,and to assist the Board your license. When the Board issues your Commissioners of Administration,Finance, in conducting a background investigation of license,all of the information that you have and Revenue;the Minnesota Legislative you. You have the right to refuse to supply the provided to the Board in the process of Auditor,national and international gambling information requested;however,if you refuse to applying for your license will become public. regulatory agencies;anyone purstiant to court supply this information,the Board may not be If the Board does not issue you a license,all the order,other individuals and agencies that are able to determine your qualifications and,as a information you have provided in the process specifically authorized by state or federal law consequence,may refuse to issue you a license. of applying for a license remains private,with to have access to the information;individuals If you supply the information requested,the the exception of your name and address which and agencies for which law or legal order Board will be able to process your application. will remain public. authorizes a new use or sharing of Private data about you are available only to the following: Board members,staff of the