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<br />f , <br /> ". <br /> LG214 <br /> Minnesota LaIJJful Gambling <br />-. Premise Permit Application - Part 3 <br /> Gambllng Site Authorization <br /> I hearby consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or <br /> public safely, or agents of the commissioners, may enter the premises to enforce the law, <br /> Bank Records Information <br /> The board is authorized to inspect the bank racords of the gambling account whenever necessary to luffill <br /> requirements of current gambling rules and law. <br /> i declare that: <br /> I have read this application and ail information submitted to the board; <br /> All information is true, accurate and complete; <br /> All other required information has been fully disclosed; <br /> I am the chief executive officer of the organization; <br /> I assume full responsibility for the fair and lawful gambling and rules of the board and agree, ff.ficensed, <br /> to abide by those laws and rules, including amendments to them; <br /> A membership list of the organization will be available within seven days after it is requested by the board; <br /> Any changes in <lppiication information will be submitted to the board and local government wIThin to <br /> days 01 the change; and <br /> A termination plan will be submitted to the board within 15 days of the termination of all premise permits. <br /> Failur~ to provide required information or provKling false information .T!ay resutt in the denial D~ revocation of the <br />. license. <br /> Signature of ~executive officer OJ: I <br /> j (j /4// qcP <br /> ~~.~.....~~~......... .... ......~I~~~pll~BI~m~~~..... ....il.;..........;:::,...i..............!;.................;........................!U.li..i(:...... <br /> 1. The city 'must sign ff the gambling premises is located within city limits. <br /> 2. The county "AND township" must sign if the gambling premises is located within a township. <br /> 3. The local government (city or county) must pass a resolution specffically approving or denying the application. <br /> 4. A copy of the resolution approving the application must be attached to the application. <br /> 5. Applications which are denied by the local governing body should not be submitted to the Gambling Control Division. <br /> Township: By signature below, the township acknowledges that the organization is applying for a premises permit within <br /> township limits. <br /> City' or County'. Township" <br /> !Township Name <br /> i <br /> [Signature of person receiving application <br /> Title Date Received <br />. Is township. 0 Organized o Unorganized o Unincorporated <br /> Refer to the Instructions for the required attachments Departm.nt of Gaming <br /> Mail to: <br /> Gambling Control Division <br /> Rosewood Plaza South, 3rd Floor <br /> 1711 W. County Road B <br /> Raseville, MN 55113 \ <br />