05-23-2001 Council Agenda - Laserfiche WebLink

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Acknowledgment Page 2 oft_ Gambling Site Authorization I hereby consent that Local law enforcement offices. me 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 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. Oath I declare that: I. 1 have read this application and all information submitted to the board is Inc. accurate, and complete; 2. all other 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 aativities 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 ten 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 license. Signature of the chief executive officer (Designee may not sign) Date Local Unit of Government Acknowledgment and Approval — Ii"itthcgambhn>�premisesis within: tarty itmtta;,thcctty-mtsscstgatttus. a cauon:an 'nand mreS0 11 on- , _... On behalf of the city, I hereby acknowledge this application for lawful gambling activity at the premises located within Print name of ciry the city's jurisdiction. and that a resolution specificity approving or denying the application will be forwarded to the applying organization. Signature of city personnel receiving application Tide Date =gam • • • g.prmvsest Mt= in:. • • .. .. dal. ccotmtvjan • - to • • Ixmu • • gni.. • YiHaM. c's",bYtcrtel 3 TGrcaixmymus4'pmv ;dcatcso""`T ho can.. For the •ownshim; On behalf of the township, 1 acimowiedge 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. see 349.213, subd. 2). Print name of township Signature of township official receiving application Tide Date For the county On behalf of the county, Ihereby acimowledge this application for lawnil gambling activity at the premises located within the county's jurisdiction, and that a resolution specifically approving or denying tilt application will be forwarded to the applying organization. Print name of county Signature of county personnel receiving application Tide Dare The inform ation 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 mfuse to supply the information requested; however, if you refuse to supply this infonnadon, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a license. If you supply the information requested, the Board will be able to process your application. Your name and address will be public information when received by the Board. All the otter information that you provide will be private data about you until the Scald issues your license. When the Board issues your license, ail of the information that you have provided to the Board in the process of applying for your license will become public. lithe Board does 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 name and address which will remain public. Private data about you are available only to the following: Board mambas, staff of the Page 61 Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety: me 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 anew use or sharing of