05-28-2003 Council Agenda - Laserfiche WebLink

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Gambling Sift An(orization 1 hereby consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or public safety or agents of the commissioners, may enter the prcmix5 to enforce the lacy. Balk liecords 1 ufurmation 'I re 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 modi ly the class of' organ i %Al ion li0018010 be consistent wit II the class of permit being applied for. Acknowledgment Oath 1 declare (lint: I. I 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. l am the chief executive officer of the organ DDation; 1 assume full responsibility for the fair and lawful operation of all activities to be conducted; 5. I will familiarize myself with the latvs of Minnesota governing lawful gambling and rules of tie board and agree, if licensed, to abide by those laws and rules, including amendments to them; Page 2 of 2 6. any charges in application information NV ill be submitted to the board and local unit of government within ten days of the change; and 7. 1 understand that failure to provide required in format ionor providing false or misleading information may resit It in the denial or revocation of the license. Signature of the chief executive officer (Designee may not sign) o J 3 Date Local Unit of Government Acknowledgment and Approval lithe gambling premises is within city limits, the city must sign this application and provide a resolution. behalf of the oily, 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 application tvi 11 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 townsiti p, both the county and townshipinust sign this application. The county in ust provide a resolution, For the lownsii f: On behalf of the township, 1 acknowledge that th c organization is applying to conduct lawful ga unbli ng activity within the township 1hulls. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). nt nape of township Signature of township official receiving application Title Dale Pri For the count] On behalf of the county, 1 hereby acknowledge this application for lawful gambling activ icy at the premises located within the county's jurisdiction, and that a resolution specifically approving or denying die application will be forwarded to the applying organization. ;fire hilts-minion requested on this form (and any altachnants) will be used by the (rambling Control 13wird (Hoard) to determine your upmlilic:tions to be inndwed in lawful gambling activities in Minnesota, and to assist the Boa td in condtcling a hockgrotnxl i lle)4igal km of you. You law the right lo (Citric to supply the inhumation requested; Iuwever, if you reline tosolyly Iris inhumation, ne Board may not he able to (1010111110 your quill il'icafams ant, as a consequence, may refuw to issue you a license. Ifyou supply the infonnahou requested, the 13otud wilt be able to process your application. Print mane of county Signature of county personnel receiving application Tile Your name and nddncss will be pub! ie information when received by h he Board. All lhcollher inlimnal ion that yon provide trill be private data about you until the fiord ismes your license. When the l3oard iaucs your license, all of the information that you hate provided to the Board in the process of applying for your license will become public. 111110 13 oar() (toes 3101 issue you a license, all 1110 information you have ITovidcd in the process of applying for a license remains private, with the exception of your lame and address which will remain public. Private data about you areal riliMe only to the Billowing: I3mrd memlers, saaflof the / / Dale Board whose work assignment requires that they have access to the in for maker; the Minnesota Department of Puff is Safely; the Minnesota Attorney General; the Minnesota Commissioners of Alhn inisnli01 Finance, and Re vane; the Minnesota Legislative Auditor, national and inter utimml gambling regulatory agencies; anyare mustn't to court order; other individml Is and agencies that are specifically nadir( shed by state a federal law to love access to are intimation; indivkIuals and agencies fa which law or (egad order authorizes a new use or 31(1)1315 of information after this !twice vrxs given; and airyone with your wri lien covnd.