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Lamb ling S 1 to A uthorization I hereby consent that local law enforcement officers, the board or agents of the board, or the comm issi oner of revenue or public safety or agents of the commissioners, may enter the premi ses to enforce the law, Batik records Information The board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of curmt gambling rules and law. Organization Lane Authorization 1 hereby authorize the Gambling Control Board to mad i fy the class of organization license to be consistent with the class of permit being applied for. Acknowledgment Oath I declare that: . I have read this application and all info rmati on submitted to the board is true, accurate, and a ompl eta 2. al l other required in formation has been fully disclosed; 3. I am the chicfexecutive officer of the organ ization# 4. I assure full responsibility for the fair and lawful opamt ion of all activities to be conducted-, 5. 1 will familiarize myself with the taws of Minnesota governing 1 awf'u t gambling and rules of the board and agree, if licensed: to abide by those laws and rules, including amendments to them; Page 2 of 2 6. any changes in application information will be submitted to the hoard and local Unit of government within tent days o F the change; and 7. I understand that failure to provide requi red in format lonor prov iding false a misleading information may result in the denial or revocation of the license. Signature of the chief executive officer (Designee may not sign) t Date w■ _ L_ ocal Unit of Government Ackno vled -, m ent and AIDDroval Print name of city On behalf of the city, I hereby acknowledge this application for lawful gambling activity at the premises located within Signature ofeity personnel receiving application the city's jurisdiction, and that a resolution specifically pP approving or denying the app lication will be fonvarded to # the applying organization. Title bate : - ' Y'tI7E�rrta ii' y v' ..- r t.•v. . e ur.�. r -�ti x x rte• his " -fi -ido �'�' =�' $ �''•;." • s: • •�_ e� r vim_ t Y _ , • s r 1 ^ rr -� � " For the town shi : On behalf of the township} I acknowledge nt name of township that the organization is applying to conduct 1ar+ful gambling P ri activity within the township limits. zgrtature of town s,ti p official reeei ving application A township has rte statutory authority to approve or deny an application (N inn. 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 the prcmi ses located with in the county's jurisdi cti on, and than a resolution sp ecifi cal ly approving or denying the appl icatio n wi 11 be forwarded to the apply i ng organization., The information requested on this form (arid any altwhments) wig be used by the arnhli ng Control Board (Board) ID detrmine your qualifications to be involved in lawful gambling activities in Mnnesota, and to assist the Board in canducdng a backgmund inwstsgation of you. You have the tight to refuse to supply the ir�farmation requested; however, if you refuse to supply this information, tle Board may not be able to determ i rr, hour qualirmatibns and, as a c onsequence, may re fuse to issue you a licerse. Ifyou supply the i n fo r =ti on requested, the B card wi l l be abl a to pro cess yot r application. Print name of county Signature of county personnel receiving application Title Date Your mmnc and address wIII be pub] is information when Board whose work assignnwrt requires that they have received by the Board. Ail Iheother information that you pto,ide A I be pmralm data about y au ra ntd the Board issues your license When the Board issues your I iGense, alI of the information that you Inaie provided b the Board in the process oFapplyirg for your Ilcense will became pubiic. I f the BoW does not issue you a license, ail the infonration you have provided in the process of applying for a license remains private, w' theexception of your nary and address which will remain public. Pr irate data about you are avaiiable ordy to the following: Board members, staff of the acCMs to the information- the Minne sota E�gwtinent of Public Safety; the Hnnesota Atterrey General; Ifie Minnesota Carnmissiomrs of Adrn inistratior Fi nance, and Revenue; the Minnesota LegbIatNe' Auditor, national and international garnbli ng regulatory agencies; anyone purs=t b court order, other individuals and agencies that are spedxfica ay authorized by state or federal lair to have mess to the information; individuals and agencies for which law or legal order authorizes anew use or sharing of information affm this notice was given; and anyone with your written conset.