2002-08-14 CC Packet - Laserfiche WebLink

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Acknowledgment Page 2 of2 Gambling Site Authorization I hereby consent that local law enforcement officers, the board or agents ofthe board, or I. the commissioner of revenue or public safety or agents of tile commissioners, may enter the premises to enforce the law. Bank Records Information The board is authorized to inspect the bank record"s of tile gambling account whenever necessary to fulfill requirements of current gambling rules and law. Organization License Authorization I hereby authorize the Gambling Control Board to modifY the class of organization license to be consistent with the class of permit being applied for. Oath I declare that: I have read this application and all information submitted to the board is true, accurate, and complete; 7. 2. all other required information has been fully disclosed; 3. I am the chiefexecutive 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 myselfwith the laws of Minnesota governing lawful gambling and rules of the board and agree, iflicensed, to abide by those laws and rules, including amendments to them; 6. any changes in application information will be submitted to the board and local unit of government within ten days of the change; and I understand that failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. ~fIJ~ - ~ Signature of ~ chief executive officer (Designee may not sign) 7 -;Le9 -19 z.- Date ~~~~lediliiiliiand~l: On behalf of the city, I hereby acknowledge this :.-.pplicmion for lawful gambling activity at the premises located within the city's jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to the app lying organization. Print name of city Signature of city personnel receiving application / For the townshio: On behalf of the township, 1 acknowledge that the organization is applying to conduct lawful gambling activity within the township limits. Print name ofto"\\oTIShip A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). Signature of township official receiving application Title Date For the countv: On behalf of the county, I hereby acknowledge this application for lawful gambling activity at Print name of county the premises located within the county's jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to the applying organization. Signature of county personnel receiving application The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota, and to assist the 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 qualifications and, as a consequence, may refuse to issue you a license. If you supply the information requested, the Board will be able to process your application. Title Your name and address will be public information when received by the Board. All the other information that you provide will be private data about you until the Board issues your I icense. When the Board issues your license, all of the information that you have provided to the Board in the process of applying for your license will become public. If the Board does not issue you a license, all the information you have provided in the process of applying for a license remains priva.te, with the exception of your name and address which will remain public. Private data about you are available only to Date Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Conunissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or