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<br />Gam bliog Sit~ Authorization <br />I hereby consent that local law enforcement <br />officers. the board or agents of the board. or <br />the commissioner of revenue or <br />public sarety or agents of the commissioners. <br />may enter the premises to enfOrce the law. <br />Bank Rerords 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 rules and law. <br />Organization License Autborization <br />I hereby authorize the Gambling Control <br />Board to modifY the class of organization <br />license to be consistent with the class of <br />pennit being applied for. <br /> <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 />information submitted to the board is true. local <br />accurate" and complete; unit of government within ten days of <br />2. all other required information has been the change; and <br />fully disclosed; <br />3. I am the chief executive officer of the 7. I W1derstand that failure to provide <br />organization; required information or providing <br />4. I assume full responsibility for the fair and false or <br />lawful operation of all activities to be misleading information may result in <br />conducted; the <br />5. I will fiuniliarize myself with the laws of ~ <br />Minnesota governing lawful gambling and 0 <br />rules of the board and agree, iflicensed, to <br />abide by those laws and rules, including <br />amendments to them; <br /> <br />Acknowledgment <br /> <br />Page 2 of2 <br /> <br />. <br /> <br /> <br />"N~Ktf&"l;rM$'lfb~'h..e. <br />I {lJes.gnee IIll'Y rior SIgn) <br /> <br />Date 2 r .,__ <br />, - \P- ~G:) <br /> <br /> <br />Local Unit of Government Acknowledgment and Approval <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 />For the townshiD: On behalf of the township, I <br />acknowledge <br />that the organization is applying to conduct lawful <br />l!I'lll~p has no statutory authority to approve or <br />deny an <br />application (Minn. Stat. sec. 349.213, subd. 2). <br /> <br />Print name of township <br /> <br />. <br /> <br />Signature of township official receiving application <br /> <br />For the countY: On behalf of the county, I hereby <br />acknowledge this application for lawful gambling <br />activity at <br />the premises located within the county's jurisdiction. <br />and <br />that a resolution specifically approving or denying the <br /> <br />The information requested on this fonn (and <br />anyattachmenrs) 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, if you refuse <br />to supply this information" the Board may not <br />be able to determine your qualifications and. as <br />a consequence, may refuse to issue you a <br />license. If you supply the inronnation <br />requested, the Board will be able to process <br />your application. <br /> <br />Print name of county <br /> <br />Signature of county personnel receiving application <br /> <br />Your name and auulC~ Will De puonc <br />information when reoeived by the Board All <br />the other infurmation that you provide will be <br />private data about you until the Board issues <br />your license. When the Board issues yolD" <br />license. all of tile information that you have <br />provided to the Board in the proce.. of <br />applying for your license will become public. <br />If the Board does not issue you a license. all the <br />information you have provided in the proo::ss <br />of applying fur a license remains private. with <br />the exception of your name and address which <br />will remain public. <br /> <br />Private data about you are available only to the <br />following: Boardmernbers, staff of the <br /> <br />Board whose work assignment reqwres that <br />they have aa:ess to the information; the <br />Minnesota Department of Public Safety; the <br />Minnesota A1torney Go......; the Mimesota <br />Commissioners of Administration" Finance, <br />and Revenue: the Minnesota Legislative <br />Auditor, national and international gambling <br />regulatory agencieS; anyone pu..uant to court <br />order; other individuals and agencies that are <br />specifically authorized by state or federal law <br />to have access to the information; individuals <br />and agencies filr which law or legal order <br />authorizes a new me or sharing of <br />information after this notice was given; and <br />anyone with your Mineo consent. <br /> <br />e <br />