CCP 01-31-2000 - Laserfiche WebLink

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e , ~ Gambling Site Authorization I hereby consent 1hat 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 Record. Information The board is authorized to inspect the bank records of the gambling account whenever necessary to fUlfill requirements of cWTeJrt gambling roles and law. Organization License Autborizatlon I hereby authori2e 1he Gambling Control Board to modifY the class of organization license to be consistent with the class of permit being applied for. Acknowledgment Page 2 of2 Oath 6. any changes in application infurmation I declare thai: will be submitted to the board and local I. I have read this applicalion and all unit of government wi1hin ten days of information su~iUed to the roard is true, the change; and accura1l:, and complete; 7. I IHldersland that failure to provide 2. all otba- required infurmation has been required information or providing false or fully disclosed; misleading information may resuh in the 3. I am the chiefexecutiveofficerofthe denialorrevoaltion of the license. organization; 4. I asswnc full responsibility for the fair and lawful operation of aU activities to be ronductcd; S. I will familiarize myselfwitb the laws of Minnesota governing lawful gambling and roles of1he board and agree, if licensed. to abide by those laws and rules, including amendments to them; Signature of tile ehief exeeutive oflieer (Designee may not sign) ~ On behalf of1he city, I hereby acknowledge this application for lawful gambling activity at 1he premises located wi1hin the city's jurisdiction. and that a resolution specifically approving or denying the application wiD be furwarded to the applying organization. sid"0~reoeiVingaPP610~Z4, 00 TI& D* e e For lbe townshiD: On behalf of1he township, I acknowledge that lbe organization is applying to conduct lawful gambling activity within the township limits. A township has no S1atutory'autburity to approve or deny an application (Mi1Ul. Stat. see. 349.213, subd. 2). Print name of township TItle Signature oftownship official receiving application , , Date Fortbe countv: On behalfofthe COlHlty, I hereby acknowledge this application for lawful gambling activity at the premises located within the county's jurisdiction. and that a resolution specifically approving or denying lbe application will be forwarded to 1he applying organization. The information requested on this fonn (and any attachments) will be used by the Gambling Control Boan! (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the infonnation requested; however, if you refuse to supply 1his information. 1he Board may not be able to determine your qualificBtions and, as a consequence, may refuse to issue you a license. If you supply the information requested.lbe Board will be able to process your application. Print name of county TItle Signature of COlHlty personnel receiving application , I Date Your name and address wiD be public infonnation when received by the Board. All the other information that you provide will be private data about you Wltil the Bo ard 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 yous license, all the infonnation you have provided in the proce~ of applying for a license remains private, with the ~ception of your name and addre~ which will remain public. Private data about you are available only to the fullowing: Board members, smlfof1he Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration" Finance. and Revenue; the Minnesota Legislalive Auditor, rudionaI and international gambling regulatory agencies; anyone pursuant to court order; other ind ividuals and agencies that are specifically authorized by state or tedcnll law to have access to the information; individuals and agencies for whicb law or legal order aU1horizes a new use or sharing of information after this notice was given; and anyone with your written consent.