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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 commi~ioner of revenue or <br />public safety or agents of the <br />commissioners, may enter the premises to <br />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 modify the cla~ of organization <br />license to be consistent with the class of <br />pemtit being applied for. <br /> <br />Acknowledgment <br /> <br />Oath <br />I declare that: <br />1. I have read this application and all <br />infotmation submitted to the board is true, <br />accurate, and complete; 7. <br />2. all other required information has been <br />fully disclosed; <br />3. r am the chiefexecutive officer of the <br />organization; <br />4. I asswne 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, if licensed, to <br />abide by those laws and rules, including <br />amendments to them; <br /> <br />. <br /> <br />" <br /> <br />Page 2 on <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 />I understand that failure to provide <br />required information or providing false or <br />misleading information may result in the <br />denial or revocation ofthe license. <br /> <br /> <br />7- ~O-&2- <br />Date <br /> <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 reoolution specifically <br />approving or denying the application will be forwarded to <br />the app lying organization. <br /> <br />Print name of city <br /> <br />Signature of city personnel receiving application <br /> <br />Title <br /> <br />/ / <br /> <br />Date <br /> <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 />Date <br /> <br />For the county: On behalf of the county, 1 hereby <br />acknowledge this application for I awful gambl ing activity at Print name of county <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. Signature of county personnel receiving application <br /> <br />The information requested on this form (and <br />any attachments) will be used by the <br />Gambling Control Board (Board) to <br />determine your qualifications to be involved <br />in lawful gambling activities in Minnesota, <br />and to assist the Board in conducting a <br />background investigation of you. You have <br />the right to refuse to supply the information <br />requested; however, if you refuse to supply <br />this information, the Board may not be able <br />to determine your qualifications and, as a <br />consequence, may refuse to issue you a <br />license. If you supply the information <br />requested, the Board will be able to process <br />your application. <br /> <br />Title <br /> <br />Your name and address will be public <br />information when received by the Board. <br />All the other information that you provide <br />will be private data about you until the <br />Board issues your 1 icense. When the Board <br />issues your license, all of the information <br />that you have provided to the Board in the <br />process of applying for your license will <br />become public. If the Board does not issue <br />you a license, all the information you have <br />provi ded in the process of applying for a <br />license remains private, with the exception <br />OfyoUT name and address which will remain <br />public. <br /> <br />Private data about you are available only to <br /> <br />/ / <br /> <br />Date <br /> <br />Board whose work assignment requires <br />that they have access to the information; <br />the Minnesota Department ofPubJic <br />Safety; the Minnesota Attorney General; <br />the Minnesota Commissioners of <br />Administration, Finance, and Revenue; the <br />Minnesota Legislative Auditor, national <br />and international gambling regulatory <br />agencies; anyone pursuant to court order; <br />other individuals and agencies that are <br />specifically authorized by state or federal <br />law to have access to the information; <br />individuals and agencies fOT which law OT <br />