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Acknowledgment <br />Page 2 of 2 <br />Gambling Site Authorization <br />I herby consent that local law enforcement <br />officers. the board or agents of the board or <br />the commissioner of revenue or <br />public safety or agents of the commissioners, <br />may enter the premises to enforce the law. <br />Bank Records Information <br />The board is authorized to inspect the bank <br />records of the gambling account whenever <br />necessary to fulfill requirements ofcurrent <br />gambling rules and law. <br />Organization License Authorization <br />I hereby authorize the Gambling Control <br />Board to modify the class of organization <br />license to be consistent with the class of <br />permit being applied for. <br />Oath <br />1 declare than <br />1. I have read this application and all <br />information submitted to the board is true. <br />arcuate, and complete <br />2. all other required information has been <br />fully disclosed: <br />3. I am the chief executive officer of the <br />organization: <br />4. ( assume dill responsibility for the fair and <br />lawful operation of all activities to be <br />arnducted: <br />5. ( will familiarize myself with the laws of <br />Minnesota governing lawful gambling and <br />odes of the board and agree, if licensed to <br />abide by those laws and rides, including <br />amendments to them: <br />6. any changes in application information <br />will be submitted to the board and local <br />unit of government widen tat days of <br />the change, and <br />7. I understand that failure to provide <br />required information or providing false or <br />misleading information may resat in the <br />denial or revocation of the license. <br />gnature of the chief executive <br />officer (Designee may na sign) <br />Date <br />Local Unit of Government Acicnowiedgment and Approval <br />.e:aam. a $•premtsesinn . =car mutSa' Ccltsemustsl$L r 'alliIlcanon:and= prom mraolutton__._. ...� <br />On behalf of the city, thereby acleiowledge this application <br />for lawful gambling activity at the premises located within <br />the city's jurisdiction, and that a resolution specifically <br />approving or denying the application will be forwarded to <br />the applying organization. <br />Print name of city <br />Signature of city personnel receiving application <br />Tide <br />Date <br />ri£t&e gambhngiprem >.ses:asJocareduxattownshi <br />"lido.exa.w�...�tre ylt1 On :.. .. <br />rlIIiyYSltls�pr0. , - •" <br />exthesountgand:icwnshm,mus sty` tramapplicano <br />For the township- On behalf of the township, I acknowledge <br />that the organization is applying to conduct lawful gambling <br />activity within the township limits. <br />A township has no statutory authority to approve or deny an <br />application (Minn. Stat. sec. 349.213, subd. 2). <br />Print name of township <br />Signanat of township official receiving application <br />Tide <br />Date <br />For the countr On behalf of the county, I hereby <br />acknowledge this application for lawful gambling activity at <br />the premises located within the cowtys jurisdiction, and <br />that a resolution specifically approving or denying the <br />application will be forwarded to the applying organization <br />Print name of cowry <br />Signature of county personnel receiving application <br />Tide <br />Date <br />The information requested on this farm (and <br />any attachments) will be used by the Gambling <br />Control Board (Board) to determine your <br />qualifications to be involved in lawful gambling <br />activities in Minnesota, and to assist the Board <br />in conducting a background invesngation of <br />you. You have the right to refuse to supply the <br />information requested: however, if you refuse to <br />supply this information, the Board may not be <br />able to determine your qualifications and, as a <br />consequence, may refuse to issue you a license. <br />If you supply the information requested. the <br />Board will be able co process your application. <br />Your name and address will be public <br />information when received by the Board. All <br />the other information that you provide will be <br />private data about you until the Board issues <br />your license. When the Board issues your <br />license, all of the information that you have <br />provided to the Board in the prows of <br />applying for your license will become public. <br />If the Board does not issue you a license, all the <br />information you have provided in the process <br />of applying for a license remains private, with <br />the exception of your name and address which <br />will remain public. <br />Private data about you are available only to the <br />following Board members, staff of the <br />Page 65 <br />Board whose work assignment requires that <br />they have access to the information: the <br />Minnesota Department of Public Safety, the <br />Minnesota Ahamey General: :he Minnesota <br />Commissioners of Administration, France, <br />and Revenue: the Minnesota Legislative • <br />Auditor, national and international gambling <br />regulatory agendem anyone pusuant to court <br />order, other individuals and agencies that re <br />specifically authorized by state or federal law <br />to have access to the information: individuals <br />and agenda for which law or legal order <br />authorizes a new use or sharing of <br />