CCP 01-31-2000 - Laserfiche WebLink

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4 Acknowledgment Page 2 of2 e Gambling Site Authorization ] hereby consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or public safety or agents of the commissioners, may enter the premises to enforce the law. Bank Records Information The board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. Organization License Authorization ] hereby authorize the Gambling Control Board 10 modify the class of organization license to be consistent with the class of pennit being applied fur. Oatb 6. any changes in application information I declnre thai: will be submiued 10 the board and local 1. I have read this application and all unit of government within ten days of information submitted to the board is true, the change; and accurate, and complete; 7. I wtderstand that failure to provide 2. all other required information has been required information or providing false or fully disclosed; misleading information mny resuh in tbe 3. I am the chiefexecutive officer of the denial or revocation of1he license. organization; 4. I asswne full responsibility for the fair and law:fuI operation of aU activities to be conducted; S. I will familiarize myselfwith the laws of Minnesota governing law:fuI gambling and rules of1he board and agree, iflicensed,. to abide by those laws and rules, including amendments to them; ~~~ Signature of the chief executive olllcer (Designee may not sign) /-,9-/- 00 Date Local Unit of Government Acknowledgment and Approval On behalf of the city, I hereby acknowledge this application for lawful gambling activity at the premises located within the city's jurisdiction, and that a resolution specifically approving or denying the application will be furwarded to the applying organimtion. Si~No7t~ceivingappf)ro~1.N I 00 TI~ D~ . , i' " " ,', For the townshio: On behalfofthe township, laclmowledge that the organization is applying to conduct lawful gambling activity within the township limi1ll. A township has no statutory authority to approve or deny an application (Minn. Stat. see. 349213, subd. 2). e Printname of township TI~ Signature of township official receiving application I I D~ For the countv: On behalf of the county, I hereby acknowledge this application for lawful gambling activity at the premises located within tbe county's jurisdiction, and that a resolution specifically apprdving or denying lbe application will be forwardedto the applying organi:mtion. Print name of county . ' Signature of county personnel receiving application , l I TItle D~ The infonnation requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to detmnine your qualifications to be involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a backgrOlmd investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this information. the Board may not be able to determine your qualifications and. as a consequence" may refuse to issue you a " license. If you supply the information requested, the Board will be able to process yoUr appU~ion. ~ ,. e Your name and address will be public infocmalion when received by the Board. All the other information that you provide will be private data about you until the Board issues your license. When the Board issues your license, aU of the information that you have provided to the Board in the process of applying for your license will become public. If the Board does not issue you a license, all the infonnation you have provided in the process of applying for a license remains private,. with the exception of your name. and address which will remain public. Private dam about you are avaihible only to the fullowing: Board members, staffofthe Board whose work Ms,ignmentrequires that they have access to 1he information; the Minnesota Department of Public Safety; the Mirmesota Attorney General; the Minnesota Commissioners of Administration. Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by stale or federal .8"" to have access to the information; individuals andagencles for which law or legal order aulhorizes a new use orsbaring of information after this notice was given; and anyone with. your written consent. ..