02-11-2004 Council Agenda - Laserfiche WebLink

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Chief Executive Officer's Acknowledgement and Oath. Read the following information and sign in the presence of a notary. I DECLARE THAT: I have read this application and all information submitted to the Gambling Control Board; All the information is true, accurate and complete; All other required information has been fully disclosed; I am the Chief Executive Officer of the organization; I assume full responsibility for the fair and lawful operation of all gambling activities to be conducted, I will familiarize myself with the laws of Minnesota governing gambling and rules of the Gambling Control Board and agree, if to abide by those laws and rules, including amendments to them; Any changes in application information will be submitted to the Gambling Control Board within 10 days of the change; I understand that failure to provide required information or providing false or misleading information may result in denial or revocation of the license. I have read this application and declare that all information submitted is true, accurate, and complete. Date: zed signature of chief utive officer Notary Public Seal must be current and correct; seal may not be altered. Subscribed and sworn to before me this ya(uvA,-. day of Notary public aoby ;Mall complete (all pages) of renewal application with one check made payable to the State of (Minnesota by: Licensing Contact: Email: Phone: Fax # Judi Tanberg judi.tanberg@gcb.state.mn.us (651)639 -4077 (651) 639-4073 JUDITH R. PROKOSCH NOTARY PUBLIC — MINNESOTA RAMSEY COUNTY �. ®w MY... 3/1/2004 to Gambling Control Board 1711 W Co Rd B #300 S Roseville, MN Organization #: 393 Expiration Date: 4/30/2004 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 public except for your Social Security number, which remains private. If the Board does not issue you a license, all information 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 the following: Board members, staff of the 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 legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your written consent.