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Acknowledgment Page z ofz Gambling Slte Auth01'IZBtIOn Oath 6. any changes in application information I hereby consent that local law enforcement I declare that: will be submitted to the board and local officers, the board or agents of the board, or 1. I have read this application and all unit of government within ten days of the commissioner of revenue or inforxnation submitted to the board is true, �e change; and public safety or agents of the accurate, and complete; 7. I understand (het failure to provide commissioners, may enter the premises to Z, all other required information has been required information or providing false or enforce the ]aw. fully disclosed; misleading information may result in the Bank Records Information 3. I am the chiefesecutive officer 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 r¢SpOnsibility for the fair and necessary to fixlfill requirements of current lawful operation'of all activities to be gambling rules and law. conducted; Organization License Authorization 5. I will familiarize myself with the laws of Signature of the chief executive I hereby authorize the Gambling Control ��esota governing lawful gambling and offlcer (Designee may not sign) Board to modify the class of organization �y�g of the board and agree, if licensed, to license to be consistent with the C�flSS of abide by those laws and rules, including perxnit being applied for. amendments to them; a� �,.; . . . � . Locat Unit of Government Acknowled ment and A rovat � �� _ �, ,.... ,�. . x, ,,;: ,,, , p , _ .. On behalf of the city, I hereby acknowledge this application _�t ��£��f��\��., for lawful gambling activity at the premises located within pr' n�e of ciry the city's jurisdiction, and that a resolution specifically � approving or denying the application will be forwarded to � � the applying organization. � ig ature of city personnel reCeiving application ��t.�c.�.. �:�..1t,�1t` I 2. / 2- � / C31 Title Date For townshi : On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling activity within the township limits. �'�t name of township 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). � -�- - Title Date For the coun : 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 / / Title Date The information requested on this form (and any attachxnents) will (7e used by the Gambling Control Board (Board) to deterxnine 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 infOrnaat: ion requested; however, if you refuse to setXxply` this inforxnation, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a license. ]f 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 inforxnation 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 public. If the Board does not issue you a license, all the inforxnation you have `provided in the process of applying for a license remains private, with the exception of your name and address which will remain public. Private data about you are available only to Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota 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 authorized by state or federal law to have access to the information; individuals and agencies for which law or