06-11-2003 Council Agenda - Laserfiche WebLink

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Gambling Site A uthorization 1 hereby consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or htic 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 organ ization license to be consistent with the class of permit being applied for. Acknowledgment Oath I declare that: L 1 have read this application and all information submitted to the board is true, accurate, and complete; 2. all other required information has been fully disclosed; 3. I am the chief executive officer of the organ ization; 4. I assume full responsibility for the fair and lawful operation of all activities to be / �% conducted; i 5. I will familiarize myself with the laws of : Sic ature of the chief executive Minnesota governing lawful gambling and' officer (Designee may not sign) Page 2 oft 6. any changes in application information will be submitted to the board and local unit of government within ten days of 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. rules of the board and agree, if licensed, to abide by those laws and rules, including amendments to them; ti -.y Date Local Unit of Government Acknowledgment and Approval If the gambling premises is within city limits, the city must_ sign this application and provide a resolution. On behalf of the city, I 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 app lication will be forwarded to the applying organization. Print name of city Signature of city personnel receiving application Title Date If the gambling premises is located in a township, both the county an d township must sign The county must provide a resolution. 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). his application. nt name of township Signature of township official rec ng 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 approving or denying the application will be forwarded to the applying organization. The information requested on this form (and any attachments) will le used by the Gambling Control Beard (Board) to determine your qualifications to be i rnolved in lawful gambling activities in Minnesota, and to assist the Board in conducting a backgrourxl investigation of you. You have the right to refuse to supply the information requested: loweve r, if you refuse supply this in tonnati on, the Board may not be able to .etennine your qualifications atxl, as a consequence, may re Inc to issue you a license. I fyou supply the information 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 information that you provide will be private data about you until the Board issues your license. When the Board issues your license, all orate information that you have provided to the Board in the process orapplying for your license will tecorne put1 i e . I f the Board rtes not issue you a license. all the information you have provided in the process of applying for a license remains private, with the exception of your tunic and address which will remain public. Private data about you are available only to the following: Baird nnemlers. sta.: 8. . Date Beard whose work assignment requires that they have access to the information; the Minrzsaa Department of Public Safety; the Minnesota Attorney General; the MinnesotaCommissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and interrudonal gambling regulatory ngercies; anyone ptvstum to cotvt order; other individ,uls and agencies that are specifically authorized by state or federal law to have access to the i ntbrmahon; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this tmtice was given; and anyone with your written convent.