2003-05-14 CC Packet - Laserfiche WebLink

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Acknowledgment Gambling Site Authorization -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. Bank Records Information The board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. Organization License Authorization 1 hereby authorize the Gambling Control Board to modify the class of organization license to be consistent with the class of pennit being applied for. Oath 1 declare that: 1. 1 have read this application and all information submitted to the board is true, accurate, and complete; , 2. all other required information has been fully disclosed; 3. I am the chief executive officer of the organization; 4. 1 assume full responsibility for the fair and lawful operation of all activities to be cond uded; s. I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the board and agree, if licensed, to abide by those laws and rules, including amendments to them; Local Unit of Government Acknowled Page 2 of2 6. any changes in application information will be submitted to the board and local unit of government yvithin ten days of _ the change; and 7. I understand that failure to provide required informationor providing false or misleading information may result in the (2;~ L Signature of the .chief executive officer (Designee may not sign) f-~,y-(I ;t Date Print name of city On behalf of the city, I hereby acknowledge this application for lawful gambling activity at the premises located within the city's jurisdiction, mid that a resolution specifically. approving or denying the app lication will be forwarded to the applying organization. Signature of city personnel receiving application F or the township: On behalf of the township, I acknowledge nt name 0 f townshi p that the organization is applying to conduct lawful gambling activity within the township limits. / I Date Pri A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). Signature of township official receiving application I I Title Date F or the county: On behalf of the county, 1 here by acknowledge this application for lawful gambling activity at the premises located within the county's jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to the applying organization. Print name of county Signature of county personnel receiving application I Tide Date The information requested on this form (and any attachments) wiD IE used by the Gambling Control Beard (Board) tp determine your qualifications to be involved in lawful gambling activities in Minneso1a, and to assi&t 1be Board in condlEting a backgrowxl investigation of you. You IBve the right to refme to supply the information requested; mwever, if you refme to supply this information, the Board may not be able to detennine your qualifications alii, as acoosequence, 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 plblic infonnation when received by the Board. All the other information 1bat you provide will be private data abolt you until the Beard ismes your license. When 1be Board i~ues your license, all of the informatioo 1hat you have provided to the Board in the process of applying for your license win IEcome public. If the Board does not issue you a license, all the information you have p'ovided in the process. of applying for a license remains private, with the exception of your mme and address which win remain public. Private data about you are available only to the following: Beard memlErs, staff of 1be Beard whose work assignment requires that they have access to the information; the MinnesWl Depar1ment of Public Safety; 1be Mnneso1a Attoru:y General; 1be Minnesota Commissioners of Administration, Finance, and Revenw; the MinnesotaLegislative Auditor, national and intermtional gambling regulatory age~ies; anyooe pursmnt to court order; other individmls and agencies tIIlt are specificany autha-jzed by state or federal law to haveacce~ to 1he information; individuals and agencies fa- which law or legal adu au1horizes a new use or sharing of . information afterthis ootice was given; and anyone wi1h your written consent.