08-28-1996 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling Premise Permit Application - Part 2 of 2 Gambling Bank Account I;:.jormation- Bank Name Bank Account Number }i tqS l SA & IK 1 1 C�Si g OJc 0(0 Bank Address City State zip )85.0 Rfa. IC, -Sr. ST P4-14 t_, A4 A) SS 1 13 Name Naive address;; and ES of persons auth fr4d to sin d ecks and make abposrts and wr6diawals ... .. •:;. Orga matron's beeseirer.:may nbr handfc gamhffngfunds::> Address Title 4r A A e /,4 AJ PI .091 /t<tlj RA-y N tin (iA'( SDA) p_« e_dgr- Acknowledgement Gambling Site Authorization I 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 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. Oath I declare that: •1 have read this application and all information submitted to the board is true, accurate and complete; .all other required information has been fully disclosed; • I am the chief executive officer of the organization; •1 assume full responsibility for the fair and lawful opera- tion of all activities to be conducted; • 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; •any changes in application information will be submitted to the board and local unit of government within 10 days of the change; and •1 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 chief executive office C. Lo a� Covernment Acknowledgement Date 1. The city *must sign this application if the gambling prem- ises is located within city limits. 2. The county "AND township•• must sign this application if the gambling premises is located within a township. 3. The local unit government (city or county) must pass a resolution specifically approving or denying this application. 4. A coov of the local unit of government's resolution ao- provino this aoolioation must be attached to this application, 5. If this application is denied by the local unit of government, 1 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** City or Cooy�Y Nam Sign fur of n calving appli;'on Township" Township Name Signature of person receiving application °7-,Q3' 96, Title Date Received. Reler to the instructions for required attachments Mail to: Gambling Control Board Rosewood Plaza South, 3rd Floor 1711 W. County Road B Roseville, MN 55113 Page 71 LG214(Pan 2) (R.v7129/91)