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LG214 Premises Permit Application Page 2 of 2 6/03 Data Privacy 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 premises permit. If you supply the information requested, the Board will be able to process your application. This form may require the disclosure of your social security number. If so, your social security number will be used to determine your compliance with the tax laws of Minnesota. Authorization for requiring your social security number is found at 42 U.S.C. 405 (c)(i). 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 Acknowledgment and Oath I hereby consent that local law enforcement officers, the Board or agents of the hoard, or the commissioner of revenue or public safety or agents of the commissioners may enter the premises to enforce the law. The Board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. I declare that: 1. I have read this application and all information submitted to the Board is true, accurate, and complete; 2. All required information has been fully disclosed; 3. I am the chief executive officer of the organization; 4. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 5. I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments to them; 6. Any changes in application information will be submitted to the Board and local unit of government within 10 days of the change; and 7. I understand that failure to provide required information or providing false or misleading information may result in the denial or revocation of the lice e your premises permit. When the Board issues your premises permit, all of the information that you have provided to the Board in the process of applying for your premises permit will become public except for your social security number, which remains private. If the Board does not issue you a premises permit, all the information you have provided in the process of applying for a premises permit 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, Board staff 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 consent. c Signatur&of Chief Executive Offfi/icerJ1esiiggneee may not sign) Print name 7/7it�f9./J / K'- /'/7_E Required Attachments 1. If the premises is leased, attach a copy of your lease. Use form LG215 Lease for Lawful Gambling Activity. 2. Attach the resolution from the local unit of government (city or county) which shows approval of your application. 3. For each premises permit application, a $150 annual premises permit fee is required. Make the check payable to the "State of Minnesota." Mail the application with attachments to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 Date NOTE: There is a monthly regulatory fee of 0.1% (.001) of gross receipts from lawful gambling conducted at the site. The fee is reported on the Gi Lawful Gambling Monthly Summary and Tax Return and paid with the monthly tax report. Questions? Call the Licensing Section of the Gambling Control Board at 651- 639 -4000. If you use a TTY, call the Board by using the Minnesota Relay Service and ask to place a call to 651 -639- 4000. This form will be made available in alternative format (i.e. large print, Braille) upon request.