08-26-2015 Council Packet - Laserfiche WebLink

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LG230 Application to Conduct -Site Gambling 6/15 Page 2 of 2 lAcknowf+ g'Ct nt by Unit of Govern ent: ;ApprovaE by 1 es uti n CITY APPROVAL for a gambling premises Located within city limits COUNTY APPROVAL for a gambling premises located in a township City Name: Little Canada County Name: Date Approved by City Council: Date Approved by County Board: Resolution Number: Resolution Number: (If none, attach meeting minutes.) Signature of City Personnel: (If none, attach meeting minutes.) Signature of County Personnel: Title: Date Signed: Title: Date Signed: TOWNSHIP NAME: L Local unit of government must sign. Complete below only if required by the county. On behalf of the township, I acknowledge that the organization is applying to conduct gambling activity within the township limits, (A township has no statutory authority to approve or deny an application, per Minnesota Statutes 349.213, Subd. 2.) Print Township Name: Signature of Township Officer: Title: Date Signed: CH1E ECU -ME OFFICER ((CEO AC ' 01lCil[(..I DG IENT The person signing this application must be your organization's CEO and have their name on file with the Gambling Control Board, If the CEO has changed and the current CEO has not filed a LG200B Organization Officers Affidavit with the Gambling Control Board, he or she must do so at this time, I have read this application, and all information is true, accurate, and complete and, if applicable, agree to the lease terms as stated in this application. Signature of CEO (must be CEO's signature; designee may not sign) Date Mail or fax to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113 Fax: 6Si-639-4032 No attachments required. Questions? Contact a Licensing Specialist at 651-539-1900, This publication will be made available in alternative format (i.e. large print, braille) upon request, Data privacy notice: The information requested on this form (and any If the Board does not issue a permit, all Information provided remains attachments) will be used by the Gambling Control Board (Board) to private, with the exception of your organization's name and address which determine your organization's qualifications to be involved In lawful will remain public. gambling activities in Minnesota. Your organization has the right to refuse to supply the Information; however, if your organization refuses to supply Private data about your organization are available to: Board members, this information, the Board may not be able to determine your Board staff whose work requires access to the information; Minnesota's organization's qualifications and, as a consequence, may refuse to issue a Department of Public Safety; Attorney General; commissioners of permit. If your organization supplies the information requested, the Board Administration, Minnesota Management & Budget, and Revenue; will be able to process your organization's application, Legislative Auditor; national and International gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies Your organization's name and address will be public Information when speciflcaliy authorized by state or federal law to have access to the received by the Board. All other Information provided will be private data information; Individuals and agencies for which law or legal order about your organization until the Board issues the permit. When the authorizes a new use or sharing of information after this notice was given; Board issues the permit, all information provided will become public. and anyone with your written consent.