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Ay' <br /> Acknowledgment Page 2 of 2 <br /> Gambling Site Authorization Oath 6. any changes in application information <br /> I hereby consent that local law enforcement ) declare that: will be submitted to the board and local <br /> officers,the board or agents of the board,or 1. I have read this application and all unit of government within ten days of <br /> the commissioner of revenue or information submitted to the board is true, the change;and <br /> public safety or agents of the commissioners, accurate, and complete; 7. I understand that failure to provide <br /> may enter the premises to enforce the law. 2. all other required information has been required information or providing false or <br /> Bank Records Information fully disclosed; misleading information may result in the <br /> The board is authorized to inspect the bank 3. I am the chief executive officer of the denial or revocation of the license. <br /> records of the gambling account whenever organization; <br /> necessary to fulfill requirements of current 4. I assume full responsibility for the fair and <br /> gambling rules and law. lawful operation of all activities to be <br /> Organization License Authorization conducted;I hereby authorize the Gambling Control 5. I will familiarize myself with the laws of Signature f the chief executive <br /> Board to modify the class of organization Minnesota governing lawful gambling and officer(Designee may not sign) <br /> license to be consistent with the class of rules of the board and agree,if licensed,to <br /> permit being applied for. abide by those laws and rules,including O/ <br /> amendments to them; ate <br /> Local Unit of Government Acknowled ment and A roval <br /> On behalf of the city,I hereby acknowledge this application <br /> for lawful gambling activity at the premises located within Print name of city <br /> the city's jurisdiction,and that a resolution specifically <br /> approving or denying the application will be forwarded to <br /> the applying organization. Signature of city personnel receiving application <br /> Title Date <br /> For the township:On behalf of the township,I acknowledge <br /> that the organization is applying to conduct lawful gambling Print name of township <br /> activity within the township limits. <br /> A township has no statutory authority to approve or deny an Signature of township official receiving application <br /> application(Minn.Stat.sec.349.213,subd.2). <br /> Title Date <br /> For the cog=:On behalf of the county,I hereby <br /> acknowledge this application for lawful gambling activity at Print name of county <br /> the premises located within the county's jurisdiction,and <br /> that a resolution specifically approving or denying the <br /> application will be forwarded to the applying organization. Signature of county personnel receiving application <br /> Title Date <br /> The information requested on this form(and Your name and address will be public Board whose work assignment requires that <br /> any attachments)will be used by the Gambling information when received by the Board. All they have access to the information;the <br /> Control Board(Board)to determine your the other information that you provide will be Minnesota Department of Public Safety;the <br /> qualifications to be involved in lawful gambling private data about you until the Board issues Minnesota Attorney General;the Minnesota <br /> activities in Minnesota,and to assist the Board your license. When the Board issues your Commissioners of Administration,Finance, <br /> in conducting a background investigation of license,all of the information that you have and Revenue;the Minnesota Legislative <br /> you. You have the right to refuse to supply the provided to the Board in the process of Auditor,national and international gambling <br /> information requested;however,if you refuse to applying for your license will become public. regulatory agencies;anyone pursuant to court <br /> 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 <br /> able to determine your qualifications and,as a information you have provided in the process specifically authorized by state or federal law <br /> consequence,may refuse to issue you a license. of applying for a license remains private,with to have access to the information;individuals <br /> If you supply the information requested,the the exception of your name and address which and agencies for which law or legal order <br /> Board will be able to process your application. will remain public. authorizes a new use or sharing of <br /> Private data about you are available only to the 0 <br /> following: Board members,staff of the <br />