CCP 03-29-2004 - Laserfiche WebLink

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. I DEUARETHAT: I have read this application and declare that all information submitted is true, accurate, and complete. I have read this application and all information submitted to the Gambling Control Board; All the information is true, accurate and complete; All other required information has been fully disclosed; I am the Chief Executive Officer of the organization; I assume full responsibility for the fair and lawful operation of all gambling activities to be conducted; I will familiarize myself with the laws of Minnesota governing gambling and rules of the Gambling Control Board and agree, if to abide by those laws and rules, induding amendments to them; Any changes in application information will be submitted to the Gambling Control Board within 10 days of the change; I understand that failure to provide required information or providing false or misleading information may result in denial or revocation of the rized signature of chief executive officer 10- 1'-(- tl,J Date: NoliIry Public Seal must be current and correct; seal may not be altered. Subscribed and sworn to before me this 'rP ~day of .:leD 3 . . NoliIry public Mail comDlete renewal aDDllcation bY: 1/31/2004 to: Licensing Contact: Phone: Fax # EmaiJ: Judi Tanberg (651)639-4077 (651) 639-4073 judi,tanberg@gcb.state.mn.us Omanization #: 2847 3/31/2004 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 acIiviIies in Minnesota, and to assist the Board in ronducling a background Investigation of you. You have the right to refuse to supply the information requested; 11owe\<er, if you refuse to supply this infonnation, the Board may not be able to determine your qualifications and, as a ronsequence, may refuse to issue you a license. If you supply the information requested, the Board will be able to process your application. Your name and address will be publiC information when rea!ived by the Board. All the other infonnation that you provide wili 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 wiil berome public except for your Sodal Security number, which remains private. If the Board does not issue you a license, all infomlation 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 data about you are available only to the following: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administrationr Finance, and Revenue; the Minnesota legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other Individuals and agendes that are spedficaily authorized by state or federal law to have access to the information; individuals and agendes for whidllaw or legal order authorizes a new use or sharing of information after this Notice was given and anyone with your written consent.