CCP 03-29-2004 - Laserfiche WebLink

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Your name and address will be public infbrmation v.l1en received by the Board. All the other Information that you provide will be private data about you until the Board issues Acknowledgment: and Oath I hereby consent that local law enforcement officers, 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 enforce the law. The Board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. I declare that: 1. I have read this application and all information submitted to the Board is true, accurate, and complete; 2. All required information has been fully disclosed; 3. I am the chief executive officer of the organization; 4. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 5. I will familiarize myself with the laws of Minnesota goveming lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and rules. Including amendments to them; 6. Any changes in application Information will be submitted to the Board and local unit of govemment within 10 days of the change; and 7. I understand that failure to provide required information or providing false or misleading Information may result in the denial > revocation of th LG214 Premises Permit Application Data Privacy The information requested on Illis form (and any attachments) will be used by Ille Gambling Control Board (Board) to determine your qualifications III be involved in IawfiJI garmling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have Ille right to refuse to supply Ille information requested; however, if you refuse to supply Illis Information, the Board may not be able to det.ermineyour qualifications and, as a consequence, may refuse to issue you a premises permit. If you supply Ille information requested, the Board ,..;H be able to process your application. This form may require the disclosure of your social security number. If so, your social security number will be used to determine your compliance Wth the tax laws of Minnesota. Authorization for requiting your social security number is found at 42 U.5.C. 405 (c)(i). Page 2 012 6/03 . your premises permit. When Ille Board issues your premises permit, all ofllle information Illat you have provided to the Board In the process ofapplying for your premises pennitwill become public except for your social security numbel; which remains prtvate. If the Board does not issue you a premises pemit, all the Information you have provided in the process of applying for a premises perm~ remains private, with the exception of your name and address whichwill remain public. P1ivate data abootyou are avaHable only III the following: Board members, Board staffwhose 'A<lt'k assignment requIreS that they have access to the Information; Ille Minnesota Department of Public Sarety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Rnance, and Revenue; the Minnesota Legislative _, national and international gambling regulatory agencies; anyone pursuant to court order; OIller individuals and agendes Illatare specifically authorized by state or fuderallaw to have access to the information; Individuals and agencies for which law or legal order authorizes a new use or sharing ofinformation after this notice was given; and anyone witt1 your consent. . 3 -?-tJ 'f ~ of Chief Executive Officer (DesIgnee may not sign) cs: Ivv L C (2-6 e- ---::v rJ Date Print name Required Attachments 1. Iflllepremises is leased,attach a copy of your lease. Use fOrm LG2t5 Lease for Lawful Gambling J\ctiviql. 2. Attach Ille resolution from the local unit of govemment (city or county) which shows approval of your application. 3. For each premises permit application, a $150 annual premises permit fee is required. Make Ille check payable to the "State of Minnesota." Mail the application with attachments to: GambUng Control Board 1711 West County Road B, Suite 300 Soulll Roseville, MN 55113 NlJTE: There is a monthly regulatory fee of 0.1 'lII (.001) of gross receipts from lawful gambling conducted .t the site. The fee is reported on the G1 Lawful Gamblng Monthly SUmmary and Tax Retum and paid with the monthly tax report. Questions? Call the licensing Section of the Gambling Control Board at 651-639-4000. If you use aTIY, call the Board by using the Minnesota Relay service and ask III place a call to 651-639- 4000. This form will be made available in alternative format O.e. large . Braille u .