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ACKNOWLEDGMENT GAMBLING PREMISES AUTHORIZATION I HEREBY GIVE CONSENT TO LOCAL LAW ENFORCEMENT OFFICERS, THE GAMBLING CONTROL BOARD, OR AGENTS OF THE BOARD, OR THE COMMISSIONER OF REVENUE OR PUBLIC SAFETY, OR AGENTS OF THE COMMISSIONERS, - -' TO ENTER THE PREMISES TO ENFORCE THE LAW. BANK RECORDS INFORMATION THE GAMBLING CONTROL BOARD IS AUTHORIZED TO INSPECT THE BANK RECORDS OF THE GAMBLING ACCOUNT WHENEVER NECESSARY TO FULFILL REQUIREMENTS OF CURRENT GAMBLING RULES AND STATUTES. I DECLARE THAT: • I HAVE READ THIS APPLICATION AND ALL INFORMATION SUBMITTED TO THE GAMBLING CONTROL BOARD; ALL INFORMATION IS TRUE, ACCURATE AND COMPLETE;; ALL OTHER REQUIRED INFORMATION HAS BEEN FULLY DISCLOSED; • I AM THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION; I ASSUME FULL RESPONSIBILITY FOR THE FAIR AND LAWFUL OPERATION OF ALL GAMBLING ACTIVITIES TO BE CONDUCTED; ... • I WILL FAMILIARIZE MYSELF WITH THE LAWS OF MINNESOTA GOVERNING LAWFUL GAMBLING AND RULES OF THE GAMBLING CONTROL BOARD AND AGREE, IF ISSUED A PREMISES PERMIT, TO ABIDE THOSE LAWS AND RULES, INCLUDING AMENDMENTS TO THEM; ANY CHANGES IN APPLICATION INFORMATION WILL BE SUBMITTED TO THE GAMBLING CONTROL BOARD AND LOCAL UNIT OF GOVERNMENT WITHIN TEN DAYS OF THE CHANGE; I UNDERSTAND THAT FAILURE TO PROVIDE REQUIRED INFORMATION. OR PROVIDING FALSE OR MISLEADING INFORMATION MAY RESULT IN THE DENIAL OR REVOCATION OF THE PREMISES PERMIT. SIGNATURE OF CHIEF EXECUTIVE OFFICER DATE LOCAL OVERNMENT ACKNOWLEDGMENT 1. THE CITY* MUST SIGN THIS APPLICATION IF THE GAMBLING PREMISES IS LOCATED WITHIN CITY LIMITS. 2. THE COUNTY ** AND TOWNSHIP ** MUST SIGN THIS APPLICATION IF THE GAMBLING PREMISES IS LOCATED WITHIN A TOWNSHIP. 3. FOR TOWNSHIPS THAT ARE UNORGANIZED OR UNINCORPORATED, THE COUNTY ** IS REQUIRED TO ATTACH A LETTER TO THIS APPLICATION INDICATING THE TOWNSHIPS STATUS. 4. THE LOCAL UNIT OF GOVERNMENT (CITY OR COUNTY) MUST PASS A RESOLUTION SPECIFICALLY APPROVING OR DENYING THIS APPLICATION. 5. A COPY OF THE LOCAL UNIT OF GOVERNMENT'S RESOLUTION APPROVING THIS APPLICATION MUST BE ATTACHED TO THIS APPLICATION. 6. IF THIS APPLICATION IS DENIED BY THE LOCAL UNIT OF GOVERNMENT, IT SHOULD NOT BE SUBMITTED TO THE GAMBLING CONTROL BOARD. TOWNSHIP: BY SIGNATURE BELOW, THE TOWNSHIP ACKNOWLEDGES THAT THE ORGANIZATION IS APPLYING FOR A PREMISES PERMIT WITHIN TOWNSHIP LIMITS. CITY* OR COUNTY ** TOWNSHIP ** CITY OR CO NAME TOWNSHIP NAME S IGNA E 0/ / nip" /i TI L PERSON RE�/ I ING APPLICATION I. SIGNATURE OF PERSON RECEIVING APPLICATION DATE RECEIVED TITLE DATE RECEIVED REFER TO THE Page 4 RED ATTACHMENTS MAIL L BOARD 1711 .. ____.__. _.... TE 300 S ROSEVILLE, MN 55113