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Your name and address will be publie Information when received by the Board. All the other Information that you provide wiD be private data about you until the Board Issues Acknowledgment and Oath I hereby oonsent that local law enforcement officers, the Board or agents of the board, or the commIssioner of revenue or pubDc safety or agents of the commissioners may enter the premises to enforce the law. The Board or agents of the board, or the commissIoner of revenue or public safety or agents of the commissIoners are authorized to Inspect the bank records of the gambllngacoount whenever necessary to fulflJl requIrements of current gambDng rules and law. I declare that: 1. I have read this app.licatlon and all Information submitted to the Board Is true, accurate, and complete; 2. All required Information has been fully disclosed; 3. I am the chief executive officer of the organization; 4. I assume full responsibility for the fair and lawful operation of aD activities to be 'conducted; 5. 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, Indudlng amendments to them; . . 6. Any changes In application Information will be submitted to the Board and local unit of government within 10 days of the change; and 7. I understand that failure to provide r~uired InfoJ:tTlatlon or providing false or misleading Information may result In the denial or 'on of tlie lIcense. x' Signature of Chief Executi Officer (Designee may ot sign) Print name Y~M.A-'I '\\.. ~o. ~\t:- - --,- ------- -- --- LG214 Premises. Permit Application Data Privacy The information requested on this form (and anyatt:achmentS) ..viIi \-~ iSl'.l111v the Gambli'l!). '.:,~oI Boarcl (Board) toO 1 '1ete!""ll!1~ j/l)U1 qualiflcatlons 'CO be lnvoived Ir. !awful gambling acttvitle WI Minnesota, anom assIStthe Board!11 conducting a background investigation of you. You have the right to refuse to supply the information requE$ted; howevelj if you refuse to supply this information, the Board may not be able to determine your qua1lflcal:lons and, as a consequence, may refuse to Issue you a premises permit. If you supply the information requested, the Board wDl be able to process your application. This form may require the disclosure of your sodal security number. If so, your social security number will be used to determine your compliance with the tax laws of Minnesota. Authorization for requiring your social security number Is found at 42 U.S.c. 405 (eX!). Required Attachments 1. If the premIseS Is leased, attach a copy of your lease. Use form LG215 LeaSe for Lawful Gambling Activity. 2. Attach the resolution from the 10caI unit of government (city or county) which shows approval of your application. 3. For each premISes permit appUcatlon, a $150 annual premises permit fee Is required. Make the check payable to the nState of Mlnnesota.D Mail the appUcatlon with attachments to: GambUng Control Board 1711 west County Road B, SUite 300 South RosevIDe, MN 55113 page2of2 8/05 your prernIses permit. When the Board Issues your premises permit. all d the information that ....ou have provided to the Board II" the process of applying fot'ltllJI OI"P.mises permit will become publk I except for your sodal seaJr!ty "umber. whlcl't remains prrvate. If . the Board does not: IssUe you a premises permit, aU the information you have provided in the process of applying for a premises permit remains private, with the exception of your name and address which will remain public. PrIvate data about you are avaDable only to the foDowIng: Board members, Board st:a.ffwhose work assignment requires that they have access to the information; the MinneSota Department d Public Safety; the Minnesota Attorney General; the Minnesota Commissioners ri Admlnlsl:ratlon, Rnance, and Revenue; the MInnesota legislative AudItor, national and International gamblIng regul!Jl:Ory agencIes; anyone pursuant to court order; other IndMduals and agendes that are speclflcaUy authorized by state or federal law to have access to the information; IndIviduals and agencies for which law or legal order authorizes a new use or sharing ri information after this notice was given; and anyone with your consent. t 5/J 101 Date NOTE: There Is a monthly regulatory fee of 0.1% (.001) of gross recelpJs from lawful gambnng conducted at the site. The fee Is reported on the G1 Lawful GambDng Monthly Stlmmary and Tax Return. and paid with the monthly tax report. Questions? CaD the Ucenslng SectIon rithe Gamb\lng Control Board at 651-639-4000. If you use a IT(, caD the Board by using the Minnesota Relay ServIce and asl<to place a call to 651-639- 4000. .' 35