05-14-2003 Council Agenda - Laserfiche WebLink

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Gambling Site Authorization 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 premises to enforce the law, Bank Records 1 Mir rum tion 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 1 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: I. 1 have read this application and all information submitted to the board is true, accurate, 2. all other required information has been fully disclosed; 3. I am the chief executive officer of the organ iznt ion; 4. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 5. 1 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; and complete; Page 2 of 2 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. 1 understand that failure to provide required informationor prov iding false or nnisi eading information may result in the denial or revocation of the license. Signature of the chief executive officer (Designee may not sign) ezuet 3 Date Local Unit of Government Acknowledgment and Approval: If the .gantbling premises is within city Iitiiits, the city must sign this application and provide 'a resolution.': On behalf of the city, 1 hereby acknowledge this application for lawful gambling activity at the premises located within the city's jurisdiction, and that a resolution specifically appro ving or denying the application will be forwarded to the applying organization. Print name of city Signature of city personnel receiving application Title Date 1 Iithe' gambling p einises is. locatedinatowwltshtp bottuthecountyandtownshipnustsigilthsapptt aii n 'the county must provide aresolution. For the township: On behalf of the township, 1 acknowledge that the organization is applying to conduct lawful gambling activity within the township limits. A townsh ip has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). nt name o f townshi p Signature of township official receiving application Title Date Pri For the county: On behalf of the county, I hereby acknowledge this application for lawful gambl ing activ ity 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 b: used by the (jumbling Control Baud (Board) to determine your quill lieu lions to he imulvcd in lawful gambling activities in Minnesota,agd to assist the Goad in conducting a backgnnud imusligatiun of yon. You lane the right to refuse to sul3 ly the information requested; Inwc or, if you ref me to supply this information, Ile Board may not he able to determine yourqualificatkms ad, as a consequence, may refits: to issue you a license. If you supply the intiamaon rerptested, tie 13 oed will be able to process yens opal icatk,a. Print nave of county Signature of county personnel receiving application Title Your mane 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 lSund iscres yua Iicense. When Uhe Board issues your license, all of the information that you have provided to the 13oard in the process of applying for your license will biome pubic. I f the Board roes net issue you a license, all the inl'onnatioa you have provided in the process of applying for a license remains priwle, with 1I1C exception of your mate and address which will retrain public. Private data about you are available only to the following: 13wrd mem tars, staff of the Date Bran' whose work assignment requires that they have access to the information; the MI inesaa Department of Public Safety; the Minnesota Attorney General; Uhe Minnesota Comm i55iaer5 of Administration, Finance, and Revenge; the Minnesota Legislatihe Auditor, national and intermtional gambling regulatory agencies; :anyone prrsmnt to coat order; other individuals and agencies that are specifically authorized by state a federal law to have access to the i 111th 'nation: individuals and agencies fa which law or legal arbr authorizes anew use or.stnri ng of i nl'onnaSon after this notice was given; and anyone with your written comet.