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This publication will be made available in altemative format (Le. large print, braille) upon request <br />Questions on this form should be directed to the Licensing Section of the Gambling Control Board <br />at (612)639 -4000. <br />Hearing impaired individuals using a TDD may call the Minnesota Relay Service at <br />1- 800 - 627 -3529 in the Greater Minnesota Area or 297 -5353 in the Metro Area. <br />Pursuant to Minn. Stat. 13.04, Subd. 2 you are hereby informed that the information requested on <br />this form will be used by the Gambling Control Board to determine your qualifications to be in- <br />volved in lawful gambling activities in Minnesota, and to assist the Gambling Control Board in <br />conducting a background investigation of you. You have the right to refuse to supply the informa- <br />tion requested. However, if you refuse to supply this information, the Gambling Control Board may <br />not be able to determine your qualifications and, as a consequence, may refuse to issue you a <br />license. If you supply the information requested, the Gambling Control Board will be able to <br />process your application. <br />Upon receiving a lawful gambling license, all application data provided by you will become public <br />data. Prior to receiving a license, the application information (with the exception of your name and <br />address which are public) is considered private data on individuals and will be available only to the <br />following: Gambling Control Board members, staff of the Gambling Control Board whose work <br />assignment requires that they have access to the information, the Minnesota Department of Public <br />Safety, the Minnesota Attorney General, the Minnesota Commissioners of Administration, Finance, <br />and Revenue, the Minnesota Legislative Auditor, national and international gambling regulatory <br />agencies, parties to judicial proceedings pursuant to court order, other individuals or agencies that <br />may be specifically authorized by state statute or federal law to have access to such information, <br />individuals and agencies for which law or legal order authorizes a new use or sharing of the infor- <br />mation after this Notice was given. <br />Page 24 <br />