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<br />Gambling Site Authorization <br />I hereby consent that local law enforcement <br />officers, the board or agents of the board, or <br />the commissioner of revenue or <br />public sarety or agents of the commissioners, <br />may enter the premises to enforce the law. <br />Bank Records Information <br />The board is authorized to inspect the bank <br />records of the gambling account whenever <br />necessary to fulfill requirements of current <br />gambling rules and law. <br />Organization License Authorization <br />I hereby authorize the Gambling Control <br />Board to medii)' the class of organization <br />license to be consistent with the class of <br />permit being applied for. <br /> <br />Acknowledgment <br /> <br />Oath <br />I declare that: <br />1. I have read this application and all <br />information submitted to the board is true, <br />accurate, and complete; <br />2. all other required information has been <br />fully disclosed; <br />3. I am the chief executive officer of the <br />organization; <br />4. I assume full responsibility for the fair and <br />lawful operation of all activities to be <br />conducted; <br />5. I will familiarize myself with the laws of <br />Minnesota governing lawful gambling and <br />rules of the board and agree, iflicensed, to <br />abide by those laws and rules, including <br />amendments to them; <br /> <br />Page 2 of2 <br /> <br />6. any changes in application information <br />will be submitted to the board and local <br />unit of government within ten days of <br />the change; and <br />7. I understand that failure to provide <br />required information or providing false or <br />misleading information may result in the <br />denial orrevocation of the license. <br /> <br /> <br />Signature of the chief x cutive <br />officer (D si ee may not sign) <br /> <br />Date <br /> <br /> <br />Local Unit of Government Acknowled ment and A royal <br /> <br />On behalf of the city, I hereby acknowledge this application <br />for lawful gambling activity at the premises located within <br />the city's jurisdiction, and that a resolution specifically <br />approving or denying the application will be forwarded to <br />the applying organization. <br /> <br />Print name of city <br /> <br />Signature of city personnel receiving application <br /> <br />I_I <br /> <br /> <br />Title <br /> <br />For the township: On behalf of the township, I acknowledge <br />that the organization is applying to conduct lawful gambling <br />activity within the township limits. <br /> <br />Print name of township <br /> <br />A township has no statutory authority to approve or deny an <br />application (Minn. Stat. sec. 349.213, subd. 2). <br /> <br />Signature of township official receiving application <br /> <br />Title <br /> <br />For the county: On behalf of the county, I hereby <br />acknowledge this application for lawful gambling activity at <br />the premises located within the county's jurisdiction, and <br />that a resolution specifically approving or denying the <br />application will be forwarded to the applying organization. <br /> <br />The information requested on this form (and <br />any attachments) will be used by the Gambling <br />Control Board (Board) to determine your <br />qualifications to be involved in lawful gambling <br />activities in Minnesota, and to assist the Board <br />in conducting a background investigation of <br />you. You have the right to refuse to supply the <br />information requested; however, if you refuse to <br />supply this information, the Board may not be <br />able to determine your qualifications and, as a <br />consequence, may refuse to issue you a license. . <br />If you supply the information requested, the <br />Board will be able to process your application. <br /> <br />Print name of county <br /> <br />I_I <br />Date <br /> <br />Signature of county personnel receiving application <br /> <br />Title <br /> <br />Your name and address will be public <br />information when received by the Board. All <br />the other information that you provide will be <br />private data about you until the Board issues <br />your license. When the Board issues your <br />license, all of the information that you have <br />provided to the Board in the process of <br />applying for your license will become public. <br />If the Board does not issue you a license, all the <br />information you have provided in the process <br />of applying for a license remains private, with <br />the exception of Y our name and address which <br />will remain public. '. <br /> <br />Private data about you are available only to the <br />following: Board members, staff of the <br /> <br />I_I <br /> <br />Date <br /> <br />Board whose work assigrnnent requires that <br />they have access to the information; the <br />Minnesota Department of Public Safety; the <br />Minnesota Attorney General; the Minnesota <br />Commissioners of Administration, Finance, <br />and Revenue; the Minnesota Legislative <br />Auditor, national and international gambling <br />regulatory agencies; anyone pursuant to court <br />order; other individuals and agencies that are <br />specifically authorized by state or federal law <br />to have access to the information; individuals <br />and agencies for which law or legal order <br />authorizesa new use or sharing of <br />