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Premises Permit Application - LG214 Page 3 of 3 1/99 Local Unit of Government Acknowledgment and Approval ff the 'rpbU LL P� • . `�' 1d > sXs �i? 414.. " _-.4pe Ica 10 T n l `..., . •' On behalf of the city, I hereby acknowledge this application for lawful gambling activity at the premises located within the city's jurisdiction, and that a Print name of city resolution specifically approving or denying the application will be forwarded to the applying organization. Signature of city personnel receiving application Title Date / / ,. ., ems. V. _ � . . . N. • r*s.CS ' * , , ` �F � S . . 54 ..�*r -� For the townshin: On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling activity within the township Print name of township limits. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). Signature of township official acknowledging application Title Date / / For the county; On behalf of the county, I hereby acknowledge this application for lawful gambling activity at the premises located within the county's Print name of county jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to the applying organization. Signature of county personnel receiving application Title Date / / The information requested on this form (and any premises permit, all of the information that you have attachments) will be used by the Gambling Control Board provided to the Board in the process of applying for your (Board) to determine your qualifications to be involved in premises permit will become public except for your Social lawful gambling activities in Minnesota, and to assist the Security number, which remains private. If the Board does Board in conducting a background investigation of you. not issue you a premises permit, all the information you You have the right to refuse to supply the information have provided in the process of applying for a premises requested; however, if you refuse to supply this permit remains private, with the exception of your name information, the Board may not be able to determine your and address which will remain public. qualifications and, as a consequence, may refuse to issue you a premises permit. If you supply the information Private data about you are available only to the following: requested, the Board will be able to process your Board members, staff of the Board whose work application. assignment requires that they have access to the information; the Minnesota Department of Public Safety; This form may require the disclosure of your Social the Minnesota Attorney General; the Minnesota Security number. If so, your Social Security number will Commissioners of Administration, Finance, and Revenue; be used to determine your compliance with the tax laws the Minnesota Legislative Auditor, national and of Minnesota. Authorization for requiring your Social international gambling regulatory agencies; anyone Security number is found at 42 U.S.C. 405 (c)(). pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to Your name and address will be public information when have access to the information; individuals and agencies received by the Board. All the other information that you for which law or legal order authorizes a new use or provide will be private data about you until the Board issues sharing of information after this Notice was given; and your premises permit. When the Board issues your anyone with your consent.