CCP 07-29-2002 - Laserfiche WebLink

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Gambling Site Authorization I hereby consent thal local law enforcement officers, the board or agents of the board, or the comrnissionerofrevenue or public safety or agent<; of the cOllnuissioners, may enter the premises to enforce the law. Bank Records lnformation The ooard is authori7.ed to inspect the bank records of the gambling account whenever necessary to fulfill requirements ofctllTCnt gambling rules and law. Organization License Authorizatio n I hereby authorize the Gambling Control Board to modify the class of organization Hcenre to be consistent with the class of permit being applied foT. Acknowledgment Oath I dec lare that: I. I have read this application <lnd all infonnation submitted to the board is true, accurate, and complete; 7. 2. all other required information has been fully disclosed; 3_ lamthechiefexe<::utiveofficerofthe organization; 4. I assume full responsibility for the fair and lawful operation of all activities to he conducted; 5. I wilt familiarize myscifwith the laws of MiImesota governing lawful gambling <lnd rules of the board and agree, if licclN':d, to abide by those laws and rules, including amendments to them; A.. irA (>>JYl&-r! 13> 7tL Page 2 of2 6. any changes in application information will be submitted to the bctard and local unit of government within ten days of the change; and I understand that failure to provide required information or providing false or misleading infonnation may result in the denial or revoC<ltion of the license. . Signature of the chief executive offic (Designee m. not sign) / Date . .. .. Local Unit of Government AekI1~_ ~l_~,j.~ ........ ~ On behalf of the city, [hereby ""knowledge this application CI N oF" /}.JljJrYJ &l-LS for lawful gamhling activity at the premises located within p~~ nf city .~ the: city'sjurisdi(;tion, and that a re9::>1ution specifically ./1 approving or denying the application will be forwarded to ~ ! l..- the applying organization. Sign ture of city per~nncl receivlOg application O:t[ 11i.h1'? ufilr\. 0; / ()2 / 1...&:Jl. Date For the township: On behalf of the township, I <l(;knowledge that the organization is applying to conduct lawful gambling activity within the township limits. Print name of township . A township has no statutory authority to approve or deny an application (Minn. Stat ~c. 349.213, subd. 2). Signature of township official receiving application /_1_- Title For the county: On behalf of the county, I hereby acknowledge this application for l<lwful gambling activity at the premises located widIin the county's jurisdiction, and iliat a resolution- specifically approving or denying the application will be forwarded to the applying organization. The information requested on this form (and any attaclunents) wHl be used by the Gambling Control Board (Board) to determine your qualificati.ons to be involved m lawful gambling activities in Mirrnesob, and to assist the Board in conducting a backgrOlU1d investigation of you. You have the right to re filSe to supply dIe informar.ion requested; however, if you refuse to supply tIllS information, the Board may not be able to determine yourquaJifkations and, as a Cf>nscquenu:; may refuse to issue you <l licenx. If you supply the information nqucsted, the Board will be able to process your application. Print n::une of cOlmty Date Signature of county personnel receiving application Tille Your name and address will be public infonnation when rc(;eived by the Board. All the other infornmtion 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 Bo ard in the process of applying for your license will become public. If the Hoard does not is<>ue you a license, all the information you have provided in the process of applying for a licen~ remains private, with the exception of your name and address which will remain public. Private data about you are available only to /---.1-- Date Board whose work assigrunent requires that they have a<:ccss to the infonnation; the Minnesota DepartmcntofPublic Safety; the Minnesota Attorney General; the Minnesota Connnissioners of Administration, Finance. and Revenue; the MUUlesota Legislative Auditor, nmonal and international gambling regulatory agencies; anyone pursuant to court order, other individuals <lnd agencies that are specifically authorized by state or federal law to have access to the infonnation; individuals and agencies for which lawor .