CCP 02-14-2000 - Laserfiche WebLink

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Gambling Sit!: Authorization I hereby consent that local law enforcement officelS. 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 enrorce 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 roles and law. Organization License Authorization I hereby authorize the Gambling Control Board to modifY the class of organization license to be oonsistent with the class of pennit being applied for. Acknowledgment Page 2 of2 Oath 6. any changes in application I declare that: information I. I have read this application and all will be submitted to the board and infonnation submined to the board is true, local 8CClU'ate, and complete; unit of government within ten days of 2. all other required infonnation has heen the change; and fully disclosed; 3. I am the chief executive officer of the 7. I understand that failure to provide organi2lltion; required information or providing 4. I asslDDe full responsibility for the fair and false or lawful operation of all activities to be m. a conducted; the . 5. I will fiuniliBrize myself with the laws of ~ Minnesota governing lawful gambling and roles of the board and agree. iflicensed, to abide by those laws and rules, including amendments to them; e 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 ell, OF iii!....) ~)ityfJ1orr ~~~ Signature of city personnel receiving application I I v, V ()() I I . " ,,', '''' t " "' , " " , ~ ") \ c, , f, , , ". I ,'. -"s)ljAi,~11 For the townshio: On behalf of the township, I acknowledge that the organization is applying to conduct lawful llI'Il~p has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). e Print name of township Signature of township official receiving application , , For the county: On behalfofthe county, I hereby acknowledge this application for lawful gambling activity at the premises located within the county's jmisdiction, and that a resolution specifically approving or denying the . '''' The information requested on this form (and any attachments) will be used by the Gambling Control Board (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 information requested; however, .ifyou refuse to supply this information, the Board may not be able to detennine your qualifications and, as a consequence. may refuse to issue you a license. If you supply the in:li:nmation requested, the Board will be able to process your application. . Print name of county . Signature of county personnel receiving application Your name and adQn::~ WUI De PUDIlC Hoard whose work 8SS1gnDJCnt"'iiqwres that information when received by the Board. All they have access to the information; the the other inronnation that you provide will be Minnesota Department of Public Safety; the private data about you wrtil the Board issues Minnesota Attorney Oenend; the Minnesota your license. When the Board issues your Commissioners of Administration, Finance. license, aU of the information that you have and Revenue; the Minnesota Legislative provided to the Board in the process of Auditor, national and international gambling applying for YOlD'" license will berome public:. regulatory agencies; anyone pu:rsuant to court If the Board does not issue you a license, all the order; other individuals and agencies that are infonnation you have provided in the process specifically authorized by state or federal law of applying fur a license remains private. with to have access to the information; individuals the exception of your name and address which and agencies fur which law or legal order will remain public. authorizes a new uSe or sharing of infonnation after this notice was given; and anyone with your written C9JlSCOl . Private data about you are available only to the following: Board members, Slaffofthe e