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Acknowledgment Page 2 of 2 Gambling Site Authorization Oath 6. any changes in application information I hereby consent that local law enforcement j d��are that: will be submitted to the board and local officers, the board or agents of the board, or 1. ( have read this �p��Cation and all unit of government Withltt ten days of the commissioner of revenue or information submitted to the board is true, the change; and public safety or agents of the accurate, and complete; 7. 1 understand that failure to provide commissioners, may enter the premises to 2. all other required information has been required information or providing false or enforce the law. ��y disclosed; misleading information may result in the Bank Records Information 3. I am the chief executive o�cer of the denial or revocation of the license. The board is authorized to inspect the bank organization; � records of the gambling account whenever 4. I assume full responsibility for the fair and necessary to fulfill requirements of current lawful operation of all activities to be gambling rules and law. conducted; Organization License Authorization 5. 1 will familiarize myselfwith the laws of Signature of the c6ief e ecutive I hereby authorixe the Gambling Control Minnesota governing lawful gambling and officer (p�j�� may pOt 51g11? Board to modify the clam 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 �� '-a g� d� permit being applied for. amendments to them; a e Local Unit of Government Acknowled ment and A roval On behalf of the city, I hereby acknowledge this application C�� o� Ro.se�tt� fp for lawful gambling activity at the premises located within Print name of city the city's jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to l.�f �� the applying organization. ►gna re of city p sonnel recCiv'Ing application Fi�id�ic�r. �Nu[v.��h i�� / I.l / O I TiNe Date For the townshio: On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling print name of township activity within the township limits. A township has no statutory authority to approve or deny an Signature of township official receiving application application (Minn. Stat sec. 349.213, subd. 2). �- 1 - - Title Date For the wuntv: On behalf of the county, I hereby acknowledge this application for lawful gambling activity at ��t 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 personnel receiving application / / Tide Date The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to 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 determine 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. 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 information that you have provided to the Board in the process of applying for your license will become publia lf 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 exception ofyour name and address which will remain publ ic. Private data about you are available only to the following: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Departrnent of Public Safety; the Minuesota 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 eufhoriud by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing