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<br />. <br /> <br />- <br /> <br />. <br /> <br />The Information reqlJ~d on this form (and any attachrnent<i) will be used by the Gambling Control Board (Board) to determine your qualifications to be <br />InvOlved in lawful gambling activities in Minnesota. and to assist: ttle Board in conducting a background investigation ill you. You have the right to refuse <br />to suppfy the Information requested; however, it you refuse to supply this lnfonnation, the Board may not be able to detenTline your qvalifJCafiOns and, 215 <br />a consequence, may refuse to register you. 1r you supply the information requested, the Board will be able to register you. <br /> <br />You are rcqt.lired to provide your Soda! Security num~ on this form. Your SOCial secunty number will be used to determine your compliance wtth the tax <br />laws of Minnesot:(!, Authorlzation for-requiring yourSodal Security number lSfound at 42 U.S.c. 40S (cXi). <br /> <br />YOur name and address will be public information when received by the Board. All other Information yOU prOVIde wilt tu:' private data until the Board <br />approves. your reglstrotlon, all information tnat you have provided to the Board In the process of registering w~1 become publiC except for your Social <br />Security number, whkil mnains private. If the Board does not approve your regIStration, aU lnfonnation you have provided in the process of registering <br />remains private, with the extepl:ion of your Rame and address whld'l wUI remain publlC_ <br /> <br />Priyal:2 data about you are avalable only to the folowlf'19: Board members, staff d the Board whose wOl'k assignment requires thiJ't they have a<:cess to <br />the iRformatlon; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Admioist!'ation, Finance, <br />and Revenue; ~ Milnesota legl9ative Auditor; naUondl and international gamb6ng reguJatolY ageRCies; anyol\e pursuant to coort order; other <br />individuals and agendes that are spedticalty authorized by state or federal Jaw to have access to the Information; indMduals and ageodes for whiCh law or <br />legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent. <br /> <br />Questions on this form should be directed to the Gambling Control BoaJ'd at 651-639-4000. If you use a TTY, call the Board t1f USing the MinnesoL"l -Relay <br />5eMce and ask to place a can to 651--639-4000_ This publication wi" De made available In alternative format (i.e. large print, Braille) upon request. <br /> <br />:1 Return license renewal application to: .1' State of Minnesota <br />Gambling Control Board <br />1711 W Co Rd B #300 South <br />Roseville, MN 55113 <br /> <br />Ucensing contact Roxie Rolph <br />roxie.rolph@gcb.state.mn.us <br />Phone (651)639-4079 <br />Fax (651)639-4073 <br /> <br />BHon <br /> <br />Monday, December 06, 2004 <br /> <br />Sod <br /> <br />P~^e!'(! <br /> <br />d~S:10 SO 10 qa~ <br /> <br />0j,BI-EB~-E9~ <br /> <br />mopa~s <br />