06-11-2003 Council Agenda - Laserfiche WebLink

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Gambling Site Authorization I hereby consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or blic safety or agents of the .mmissioners, may enter the premises to enforce the law. Bank Records Information The board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. Organization License Authorization I hereby authorize the Gambling Control Board to modify the class of organization license to be consistent with the class of permit being applied for. Acknowledgment Oath I declare that: 1. I have read this application and all information submitted to the board is true, accurate. and complete; all other required information has been fully disclosed; 3. I am the chiefexecutive officer of the organization; 4. I assume full responsibility for the fair and lawful operation of all activities to be cond uctcd; 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; 2, Page 2 of2 6. any changes in application information will be submitted to the board and local unit of government within ten days o f the change; and 7. I understand that failure to provide required informationor providing false or misleading information may result in the denial or revocation of the license. Signature of the chief executive officer (Designee may not sign) '. y •i3 Date Local Unit of Government Acknowledgment and Approval If the gambling premises is within oily limits, the city must sign this application and provide a resolution. On behalf of the city, [ hereby acknowledge this application for lawful gambling activity at the premises located within the city's jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to the applying organization. Print name of city Signature of city personnel receiving application Title Date If the gambling premises is boated in a township, both the county and township must sign this application. The county must provide aresolution. For the township: On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling activity within the township limits. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). nt name of township Signature of township official receiving application Title Date Pri For the county: On behalf of the county, I hereby acknowledge this application for lawful gambling activity at the premises located within the county's jurisdiction, and that a resolution specifically ap proving or denying the application will be forwarded to the applying organization. The information requested on this font (and any attachments) will ba used by the Gambling Control Board (Board) to de tennine your qualifications to be involved in lawful gambling activities in Minnesota, and to assist the Board in conducting. a backgrourxi imetigation of you. You have the right to refuse to supply the information requested; howewr, if you refuse • supply this information, the l3oard may not be able to seam tie your qualifications and. as a consequence, may refuse to issue you a license. Yvon supply the in thnnadon requested. the Board will be able to process your application. Print name of county Signature of county personnel receiving application Title Your name and address will be public information when received by the Board. All the other informaricn that you provide will be private data about you until the Board issues your license. When the Board issues your license. all of the infonnatian that you hags provided to the Board in the process of applying fbryour license will become public. If the Board gibes not issue you a license. all the information you have provided in the process of applying for a license remains pn ate. with the exception of your name and address which will remain public. Private data a bent you are avmiiable onto to the following: 13cxurd memters. sal'. 4 _ Date Board whose work assignment requires that they have access to the information; the Minnesota Department ofPublic Safety; the Minnesota Attorney General; the Minnesota Comm issiorers of Administration, Finance, and Revenue; tale Minnesota Le gislatile Auditor, national and international gunbling 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 rotor nauon. individuals and agencies for which law or legal order authorizes anew use or staring of information abler this notice was given: and anyone with your written comae tit.