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CCP 02-14-2000
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CCP 02-14-2000
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<br />Gambling Sit!: Authorization <br />I hereby consent that local law enforcement <br />officelS. the board or agents of the board, or <br />the commissioner of revenue or <br />public safety or agents of the commissioners, <br />may enter the premises to enrorce the law. <br />Bank Records Information <br />The board is authorized to inspect the bank <br />records of the gambling account whenever <br />necessary to fulfill requirements of current <br />gambling roles and law. <br />Organization License Authorization <br />I hereby authorize the Gambling Control <br />Board to modifY the class of organization <br />license to be oonsistent with the class of <br />pennit being applied for. <br /> <br />Acknowledgment <br /> <br />Page 2 of2 <br /> <br />Oath 6. any changes in application <br />I declare that: information <br />I. I have read this application and all will be submitted to the board and <br />infonnation submined to the board is true, local <br />8CClU'ate, and complete; unit of government within ten days of <br />2. all other required infonnation has heen the change; and <br />fully disclosed; <br />3. I am the chief executive officer of the 7. I understand that failure to provide <br />organi2lltion; required information or providing <br />4. I asslDDe full responsibility for the fair and false or <br />lawful operation of all activities to be m. a <br />conducted; the . <br />5. I will fiuniliBrize myself with the laws of ~ <br />Minnesota governing lawful gambling and <br />roles of the board and agree. iflicensed, to <br />abide by those laws and rules, including <br />amendments to them; <br /> <br />e <br /> <br /> <br />Local Unit of Government Acknowledgment and Approval <br /> <br /> <br /> <br />On behalf of the city, I hereby acknowledge this <br />application <br />for lawful gambling activity at the premises located <br />within <br />the city's jurisdiction, and that a resolution specifically <br /> <br />ell, OF iii!....) <br /> <br />~)ityfJ1orr ~~~ <br />Signature of city personnel receiving application <br />I <br /> <br />I <br /> <br />v, V ()() <br />I I <br /> <br />. <br />" ,,', '''' t " "' , " " , ~ ") \ c, , f, , <br />, ". I ,'. -"s)ljAi,~11 <br /> <br />For the townshio: On behalf of the township, I <br />acknowledge <br />that the organization is applying to conduct lawful <br />llI'Il~p has no statutory authority to approve or <br />deny an <br />application (Minn. Stat. sec. 349.213, subd. 2). <br /> <br />e <br /> <br />Print name of township <br /> <br />Signature of township official receiving application <br />, , <br /> <br />For the county: On behalfofthe county, I hereby <br />acknowledge this application for lawful gambling <br />activity at <br />the premises located within the county's jmisdiction, <br />and <br />that a resolution specifically approving or denying the <br />. '''' <br /> <br />The information requested on this form (and <br />any attachments) will be used by the Gambling <br />Control Board (Board) to determine your <br />qualifications to be involved in lawful gambling <br />activities in Minnesota,. and to assist the Board <br />in conducting a background investigation of <br />you_ You have the right to refuse to supply the <br />information requested; however, .ifyou refuse <br />to supply this information, the Board may not <br />be able to detennine your qualifications and, as <br />a consequence. may refuse to issue you a <br />license. If you supply the in:li:nmation <br />requested, the Board will be able to process <br />your application. <br /> <br />. <br /> <br />Print name of county <br /> <br />. <br /> <br />Signature of county personnel receiving application <br /> <br />Your name and adQn::~ WUI De PUDIlC Hoard whose work 8SS1gnDJCnt"'iiqwres that <br />information when received by the Board. All they have access to the information; the <br />the other inronnation that you provide will be Minnesota Department of Public Safety; the <br />private data about you wrtil the Board issues Minnesota Attorney Oenend; the Minnesota <br />your license. When the Board issues your Commissioners of Administration, Finance. <br />license, aU of the information that you have and Revenue; the Minnesota Legislative <br />provided to the Board in the process of Auditor, national and international gambling <br />applying for YOlD'" license will berome public:. regulatory agencies; anyone pu:rsuant to court <br />If the Board does not issue you a license, all the order; other individuals and agencies that are <br />infonnation you have provided in the process specifically authorized by state or federal law <br />of applying fur a license remains private. with to have access to the information; individuals <br />the exception of your name and address which and agencies fur which law or legal order <br />will remain public. authorizes a new uSe or sharing of <br />infonnation after this notice was given; and <br />anyone with your written C9JlSCOl <br /> <br />. <br /> <br />Private data about you are available only to the <br />following: Board members, Slaffofthe <br /> <br />e <br />
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