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Acknowledgment PaQc'of 2 Gambling Site Authorization Oath 6. anN changes in application inti:=rMali0r.. I hereby consent that local law enforcement i declare that: will be submitted to the board and J oCa� officers,the board or agents of the board,or 1,1 have read this application and al i unit of government within tell days of the commissioner of revenue or information submitted to the board is tee-, the change; and public safety or agents of the accurate, and complete: 7. 1 undo-st id that failure to provi de commissioners, may enter the premises to 2. all other required information has been required information or providing fals�:or enforce the law fully disclosed; Bank Records Information 3. l am the chief executive afficer of the misleading information my result in the `The board is authorized to inspect the bank organization; denial or revocation of the license. records of the gambling account whenever 4.I assume full responsibility for the fair and necessary to fulfill ll requirements ofcurrent lawful operation of all activities to be gambling rules and law. conducted; Organization License Authorization Signature of the chief executive 5. I will familiarize myselfwlth the laws of I hereby authorize the Gambling Control Minnesota governing lawful gambling and officer(Designee may not sign) Board to modify the class of organization rules of the board and agree, if licensed, to license to be consistent with the class of abide by those laws and rules, including permit being applied for amcndments to them; Date Local nit of overnment Acknowledgment and tip roval On behalfofthe city,I hereby acknowledge this application ► c-- _ .. for la�vful gambling activity at the premises located within Print name f city the city's jurisdiction, and that a resolution specifically � Y approving or denying the application will be forwarded to Signature of city personnel, receiving application the applying organization �► I �-� � VA Title Date ---------- I-W For thg townshiry,On behalf of the township,I acknowledge that the organization is applying to conduct lawful gambling Print name of townshi�p activity within the township limits A townsh ip has no statutory authority to approve or deny an Signature of township official receiving application application M nn.Stat. sec. 349.213,subd.2). Title Date For the county : On behalf of the county, I hereby acknowledge this application for lawful gambling activity at Print name of county the premises located within the cvuntx's jurisdiction, and that a resolution cpecifi cal ly approving or denying the —"��"�"�" �`Signature of county personnel receiving application application wi II be forwarded to the applying organization Title Date The information requested on this form(and Your name and address will be public Board whose work assignment requires that any attachments) will be used by the information when received by the Board.All they have access to the information rhr. Gambling Control Board(Board)to the other information that you provide will MU-Inesota Department of Public Safety; determine your qualifications to be involved be private data about you until the Board the Minnesota Attorney General;the in l aw ful gambling activities in Minnesota, issues your license.When the Board issues Minnesota Commissioners of and to assist the Board in conducting a your I icense, all of the information that you Administration,Finance, and Revenue; the background investigation of you. You have have provided to the Board in the process of Minnesota Legislative Auditor,national the right to retie to supply the information applying for your license will become and international gambling regulator? requested; however, if you refuse to supply public If the Board does not issue you a agencies;anyone pursuant to court order- this information, the Board may not be able license, all the information you have other individuals and agencies that arc to determine your qualifications and,as a provided in the process of applying for a speeifically authorized by state or federal consequence,may refuse to issue you a license remains private, with the exception law to have access to the information; license If you supply the information of your name and address which will remain individuals and agencies for which iaw or requested,the Board will be able to process public legal order authorizes a new use or sharing your application of information after this notice was given; Private data about you are available only to and anyone with your written consent the following: Board members, staff of"the