2002-09-25 CC Packet - Laserfiche WebLink

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Gambling Site Authorization 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. Bank &cords fuformation The board is authorized to inspect the bank records of the gambling ~count whenever necessary to fulfill requirements of current gambling mles 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 pennit being applied for. Acknowledgment Oath ] declare that: 1. I ha\i:e read this application and all info rmation 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 fun 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 roles of the board and agree, if licensed, to abide by those laws and rules, including amendments to the~ , Page 2 of2 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 und.erstand that failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. 7-,7.'::/-<::>2.-- Date On behalfofthe city, I hereby acknowledge this application I for tawful gambling activity at the premises located within Print n e of city ~/ the city's jurisdiction, and that arerolutionspecifically ~ ./ ~ t';'::;' approving or denying the application will be forwardelf tn _" ~4.i" AA9~ J.t..-.;" AI!:, / the applying organization. Signa.u;re of ci personnel receiving application l' /~ tfJ /.., Date Title For the townshio: On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling activit)' within the township 15mi15. Print name oftownship 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 county: On behalf of the county, 1 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 persQnnel receiving application The information requested On this fonn (and any attachments) will be used by the Gambling Control Board (Board) t6 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 deterniine 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 license. When the Board issues your license, all of the infortnation 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 private, with the e.,'Cception of your name an.d 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 Commissioners 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 iflformation; individuals and agencies for which lawor .