CCP 01-28-2002 - Laserfiche WebLink

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Acknowledgment Page 2 of2 Gambling Site Authorization I hereby consent th81 local law enforcement officers, the board or agents of the board, or ]. the commissioner of revenue or public safety or agents of the cormnissioners, may enter 1he 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 taw. Organization License Authorization I hereby authorize the Gambling Control Board to modify the etaS'! of organization Iicen~ to be consistent with the class of permit being applied for. I have read this application and all information submitted to the board is true, accurate, and complete; 7. 2. all other required information has been fully disclosed; 3. I am the chief executive officer of the organization; 4. I assume full responsibility faT the fair and / "" / ..c?// lawful operation of all activities to be ~ ~~-- co ndUeled; t/;S'f th h' f . 5 I ill f '1' . If 'th th I f :.gnature 0 e c Ie executive . w ami Ianze myse WI e aws 0 .' . Minnesota governing lawful gambling and officer (DesIgnee may not SJ.,gIl) rules of the board and agree, iflicensed, to {-I<( - C? ~ abide by those laws and rules, including amendments to them; Oath I declare that: 6. any changes in application information will be submitted to the board and local unit of government within ten days of the change; and I understand tha! failure to provide required information or providing false or misleading information may result in the denial OT revocation of the license. Date Local Unit of Governm~.owled ment and AfdJroval 1~1II-_.-~- _n~lIllIll_ IU. !iIIrlII'llIlIlIIl -........ CITl OF' fit1JJrYJ /1[..[,; 6J:J 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 are!nlution specifically approving or denying the application will be forwarded to the applying organization. Il Signature of city personnel receiving application f1tf 11kqr~AA 0 \ I~ ~O(J1- Date Title For the townshio: On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling activity within the township limits. Print name of to wnship A township has no statutory authority to approve or deny an Signature of township official receiving application application (Minn. Stat ~c. 349.213, subd. 2). Tide I Date For the county: On behalf of the county,] hereby acknowledge this application for lawful gambling activity at Print name of county the premises located within the county's juris:iiction, and that a resolution specifically approving or denying the application will be fOf\\'arded to the applying organization. Signature of county personnel receiving application 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, 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 licerue-. If you supply the information requested, the Board will be able to process your application. Title Your name and address will be publ ic information 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, all 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 information 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 dala about you are availableonly to I ~ Date Board whose work assignment requires that they have access to the infonnation; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Conunissioners 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 state or federal law to have access to the information; individuals and agencies for which law or c-' K V /" ~2- e e e