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LG214 Premises Permit Application Data Privacy The inf nation Mwftd on this rn (&id any ts) Will be used by the GaMbjMg CM*d Bard (Board) to to be hw&,d k, la WV garb M aches In Knresotar and to mist the Bmrd In conducting a ground kweskigatkn of fit. You have the rift to refum to supply the k* niat ; howeverr If you refiBe to su" the infora`mtian, the Board may not be We to YOw q om and, as a crosequertiae, may refuse to hwe you a permit If you supply the lnfOmWm reqLvsW, the Board will be able to pmoess your awkaffm. ibrrn away require the dbdosure-of your soda I aunty, number. If so, your sal security number will be used to deUnWne YCW omplanom wNh the tax lam of Minnesota. Audxrl&. fbr y= sal se urty number is fourd at 42 U.S.0 40S (c Xi). Your name and address will be public inforn ut n when receive d by the Board. All the other inforr Don that you provide will be primate data amt you until bt a Board isv.res Acknowledgment and oath PSW 2 of 2 private dMa about you are available only to the foi[owing: d nmrbasr Board staff whose work t reWkw that they have aamss to the inftwmatio[1; the Minnesota Depaft t of putgic Safety; the Minim fey mil; the Minnesota CorrinlsONNss of Admini abM. canoe, and Revenue; the Minnesota Leo-dative AuchbDr, natimal and intemational gambling regulatory agencim; any cm want to court order, Oiler irdividuals and agencies that are specifically auftrLmd by stag or federal law too have a00ess tQ the Inforrrtiatk n; Individuals and agencies for wtich law or legal order autitiorizes a crew use or sharing of lnfwmtk3n after this notice was given; and anyone with your consent. I hereby consent that dal law enfomwwrtit officersr the Ward or agents of the revenue or public safety � agents of the cornrnis�ioners � ward, or the cornnllssioc�er of authorized irtis may enter- the premises to enforce the law. The Board is pest the bank records of the gambling aunt whenever necessary to fulfill iremen current gambling rules and law. I declare that: + is of I. I have read this application and ail Information submitted to the Ord is true 2-- . All required information has been fully accurate, and complete; disclosed; 3. I anti the chief executive officer of the organization; 4. I assume full responsibility for the fair and lawful operation of alI , . acbvrties to be conducted; S. I will familiarize myself with the laves of Minnesota governing awful gambling iicensed, � abide by those laws and rules irticlt�in � g g and rules of the Board and agree, if r � an'lendl7leiit� to them; E. Any changes in application Information will be submitted to the Board and I . days of the change; and local unit of gover7r ment within 7. I+ derstand that failu A to provide required Information or providing false r d ail or prn g sec misleading Information may result In o license. Signature of Chief Executive Officer (Designee may not sign Date Print name R ` R d�. � e r M 4T Required Attachment 1. If the premises is leased, attach a copy of your lease. less fbrm 1G2-15 Lease for Lawful Gambling ActWity. 2, Attach to resolution from the local unit of govemmerrt (city or county) which slows approwral of your application. 3. For each prierrtises permit appl'jmt 'r a $ISo annual pmmism Permt free is required. Make the die& payable to the wState of Minnesota, Mail the application widh aftadfuTwts to.. Carnbfiing Control Board 1711 West dunty Road B, Suite 300 South FtQW1ler MiV 55113 PKM There is a monthly regulatory fee of a.1% (.001) of grass receipts from lawful gambling conducted at the site. The fee is reported on the G 1 Lawful Gambling Monthly Summary and Tax Return and paid with the monthly tax rep orL QueWOns? Call the Ling sew of the Gamaring Control Board at 651- 639 -40. If you use a TTY call the Board by using Minnemta may Ser&e and ask to place a call to 651-639 - . This fotln will be ride available in albffmtjve format (i.e. large print B011e) umn rent