Res. #07-028 - Dead Broke Saddle Club - Sagers

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Your name and address will be public Informatlon when received by the Board. All the other Infonnatlon that you provide will be private data about you until the Board Issues Acknowledgment and Oath 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. 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 gambling account whenever necessary to fulfill requirements of current gambling rules and law. I declare that: 1. I have read this application 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 all 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, induding amendments to them; 6. Any changes In application information wlll be submitted to the Board and local unit of government within 10 days of the change; and 7. I understand that failure to provide required InfoJ:lTlatlon or providing false or misleading information may result In the denial or 'on of the license. X Signature of Chief Executi Officer (Designee may ot sign) Print namey---rr)nM~ '\\. ~ ~o. ~~~:- -- ----- ---- ---------- ---- --- LG214 Premises Permit Application Data Privacy The information requested on this form (and any attachmentS) ,1\Ii1i <-Of Jsed by the Gambling Control Board (Board) to ;jete!-rnlne your qualifications to IJe involved jnlawful gambling actlvitle, In Minnesota, and to assistthe Board in conducting a background investigation of you. 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 determine your quarlficatlons and, as a consequence, may refuse to Issue you a premises permit. If you supply the Information requested, the Board wJ1l be able to process your applIcation. ThIs form may requIre the disclosure of your sodal seaJrIty number. If so, your social seairlty number will be used to determine your complIance with the tax laws d Minnesota. Authorization for requiring your soda! security number Is found at 42 U.S.C.405 (eX!). Required Attachments 1. If the premises Is leased, attadl a copy of your lease. Use form LG215 Lease for Lawful Gambling Activity. 2. Attach the resolution from the local unit of government (city or county) which shows approval of your application. 3. For each premISes permit application, a $150 annual premises permit fee Is required. Make the check payable to the RState of Minnesota. R MaD the application with at:t:achrnerrtS 00: Gambling Control Board 1711 west County Road B, SUite 300 South Rosevllle, MN 55113 Page 2 of2 8/05 your premises permit. When the Board issueS your premises permit, all of the information that"ou have provided to the Board ir the process of applying for your premises permit will become public except for your sodal securfty !lumber. whidl remains private, 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 following: Board members, Board staff whose work assignment requires that they have access to the Infonnatlon; the MinneSota Department d Public Safety; the Minnesota Attorney General; the Minnesota Commissioners rl Administration, Rnance, and Revenue; the Minnesota legislative Auditor, national and International gambling regulatory agencies; anyone pursuant to court order; other IndMduals and agendes that are specifically authorized by state or federal law to have access 00 the Information; Individuals and agencies for which law or legal order authorizes a new use or sharing rllnfonnatlon after this notice was given; and anyone with your consent. X 51J 101 Date N01'f: There Is a monthly regulatory fee of 0.1% (.001) of gross rec:elpl:Sfrom lawful gambling conducted at the site. The fee is reported on the Gl Lawful Gambling Monthly SUmmary and Tax Return and paid with Ute monUtIy tax report. . Questions? Call the UcensIng Sedion of the Gambling Control Board at 651-639-4000. If you use a TTY, call the Board by using the Minnesota Relay ServIce and ask to place a call to 651-639- 4000.