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6,115 Peg
<br /> Premises Per Application
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<br /> ACKNOWLEDGMENT BY LOCAL UNIT OFGOVERNMENT: APPROVAL BY RESOLUTION
<br /> CITY APPROVAL COUNTY APPROVAL
<br /> for a gambling premises for a gambling premises
<br /> located within city limits located in a township
<br /> em iety -
<br /> city Na : --- County Name:
<br /> Date Approved by City Councik Data Approved by County Bozird=
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<br /> Resolution Number, -—---- Resolution Number: -------- ................................................................................----------------------------------------
<br /> a u , R
<br /> (If none,
<br /> APPROVAL
<br /> meeting minutes,) (If none.,attach unerring rninutesa)
<br /> Signature of City Personnel: Signature of County Personnel,
<br /> ..........................................................................-—----------------------------------------------
<br /> Title: ... T:Clea
<br /> Date Signed:
<br /> .......................
<br /> TOWNSHIP NAME:
<br /> ......................................
<br /> Complete below only if required by the county.
<br /> Local unit of government On behalf of the township, I and that the organization is
<br /> applying to conduct gambling activity within the township limits,
<br /> must sign. (A township has no statutory authority to approve or deny orr
<br /> application, per Minnesota Statutes 349,213, Subs, 2.)
<br /> ......................................................................
<br /> Print Township Name ——-----------------
<br /> -_ L_'Signature o "Fowns in tcera
<br /> -9 itle: ___ Date Signed
<br /> __..........
<br /> ACKNOWLEDGMENT AND OATH
<br /> 1, 1 hereby consent that local law enforcement officers, 6, 1 assume-oil responsibility for the fair and lawful operation of
<br /> the Board or its agents, and the commissioners of all activities to be conducted.
<br /> revenue or public safety and their agents may enter 7, i will familiarize Myself with the laws of Minnesota governing
<br /> and inspect the premises. lawful gambling arid rules of the Board and agree, if licensed,
<br /> 2. Fhe Board and its agents, and the commissioners of to abide by those laws and rules, including amendments to
<br /> revenue and public safety and their agents, are them
<br /> authorized to 'inspect the bank records of the garobling
<br /> account whenever necessary to fulfill requirements oB. Arry changes in application informatr n will be submitted to the
<br /> f
<br /> current gambling rules and law. Board no later than ter days after the change has taken
<br /> effect,
<br /> 3, 1 have read this application and all information 0, 1 undersstand that failure to provide required information or
<br /> I submitted to the Board is true, accurate, and complete, -
<br /> providing false or misleading information may result in the
<br /> 4, All required information has been fully disclosed, denial or revocation of me license,
<br /> 5, 1 am the chief executive officer of the organization. 1-0, 1 understand the fee is non-refundable regardless of license
<br /> approval/dental,
<br /> Signature of Chief Executive Officer(designee may not sign) Date
<br /> auto privacy notice,The information requested art this fit"orrnatrai whe.n received by the Board.,
<br /> form(arm any attachments)will be near' by the All other information provided eflil be Attorney General,Corernostoners of
<br /> Gambling Control Board(Board,to determine your private data about your ar,
<br /> lionization until Adn-Anistration,Minnesota Management A,
<br /> organization's quaflfications;tote involved ir lawful the Board issues the permit, When the Budget,and Revenue;Legislative Auditor,
<br /> b And
<br /> al and internal nal Golan
<br /> gramblins activities in Your unionization has Board issues the permit,all information none;
<br /> C
<br /> n
<br /> Revenue; u
<br /> Is
<br /> a I ol
<br /> l€riFiat!(to refUSe to SUPPlY the information; however, provided%oll hereine public, Ta.F file Board regulatory agencies;anyone pursuant to
<br /> rink,all infoi-ii nation court order,other individuadis and agencies
<br /> your organization refuses to supply this information, does net Gnus a par
<br /> so
<br /> aided re d by state or federal lay
<br /> 'me Board may not be able to deternnne your pro mvens private,with the specifically authorize
<br /> organization's qualifications and,as a consequence, excretion of your organization's narne and ?-a have,access to the infienrokion; individuals
<br /> v
<br /> may refuse to issue a permit, If your obvinization address which will ren ain public, Private and agencies flor which law or legal order
<br /> supplies the information requested,the Board will be data about your organFeation are avalkitsw authorizes a new me or sharing of
<br /> be,tprocesyour organization's application, Your to: Board rnw
<br /> ernbers,Board staff tease is once was
<br /> after-thugiven; and
<br /> I lo s
<br /> -roanization'sns�o and address will be pu[Ar: work requires access to the infor
<br /> ff Mahon; anyone with your wr two consent.
<br /> ...................................
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<br /> This form will be rnade avalbode it)alternative forinal,Le,large print,braille,upon request,
<br /> .... ......._ .
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<br /> Art ewco poeirfunfly ervivoyar,
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