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CCP 02-13-2006
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CCP 02-13-2006
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5/8/2007 1:21:17 PM
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11/14/2006 4:42:02 PM
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<br />License Number 1485 <br />Current Expiration 3{31{2006 <br /> <br />. <br /> <br />Chief Executive Officer's Acknowledgement and Oath <br /> <br />I declare that: <br /> <br />I have read this application and all information submitted to the Board. All information is true, accurate and complete. <br />All other required information has been fully disclosed. I am the chief executive officer of the organization. <br />I assume full responsibility for the fair and lawful operation of all gambling activities to be conducted. I will familiarize myself <br />with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and <br />rules, including amendments to them. <br /> <br />I certify that the gambling manager is bonded and licensed as <br />required per Minnesota Statutes. <br /> <br />I understand that failure to provide required information or providing <br />false or misleading information may result in denial or revocation of <br />the license. <br /> <br />A termination plan will be submitted to the Board within 30 days of <br />termination of our gambling operation. <br /> <br />I have read this application and declare that all <br />informa~11 submitted is tr ,accurate, and <br />complet r L <br /> <br /> <br />Signature, in ink/ of chief executive officer <br /> <br /> <br />Date: ~~ 0 (; <br /> <br />Mail complete renewal application (all pages), and <br />one check made payable to the State of Minnesota <br />for all renewal fees by: 1/30/2006 <br /> <br />to: Gambling Control Board <br />1711 W Co Rd B #300 S <br />Roseville, MN 55113 <br /> <br />Licensing Contact: <br />Email: <br />Phone: <br />Fax #: <br /> <br />Deb Lewis <br />deb.lewis@gcb.state.mn.us <br /> <br />(651) 639-4073 <br /> <br />The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to detennine your <br />qualifications to be involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. <br />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 <br />determine your qualifications and, as a consequence, may refuse to issue you a license_ If you supply the information requested, the Board will <br />be able to process your application. <br />Your name and address will be public information when received by the Board. All the other information that you provide will be private data <br />about you until the Board issues your license. When the Board issues your license, aU of the information that you have provided to the Board in <br />the process of applying for your license will become public except for your Social Sea..lrity number, which remains private. If the Board does not <br />issue you a license, all information you have provided in the process of applying for a license remains private, with the exception of your name <br />and address which will remain public. <br />Private data about you are available only to the following: Board members, Board staff whose work assignment requires that they have access <br />to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, <br />Finance, and Revenue; the Minnesota legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court <br />order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and <br />agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your written <br />consent. <br /> <br />. <br />
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