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1.0214 Minnesota LawfuL Gambling Premise Permit Application - Part 3 owled ement :? Gambling Site Authorization I heathy 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 currant gambling rules and law. 1 declare that: I have read this application and all information submitted to the board; All information is true, accurate and complete; All other required information has been fully disclosed; am the chief executive officer of the organization; 1 assume full respcnsibiliy for the fair and lawful gambling and rules of the board and agree, if licensed, to abide by those laws and rules, including amendments to them; A membership list of the organization will be available within seven days after it is requested by the board; Any changes in application information will be submitted to the board and beat government within 10 days of the change; and A termination plan will be submitted to the board within 15 days of the termination of all premise permits. Failure to provide required information or providing false information may result in the denial or revocation of the license. of chief executive officer vernmeat.Acknowiedgemer t Dana 1/28/91 1. The city *must sign if the gambling premises is located within city limits. 2. The county "AND township" must sign 11 the gambling premises is located within a township. . 3. The heal government (city or county) must pass a resolution specifically approving or denying the application. 4. A copy of the resolution approving the application must be attached to the application. 5. Applications which are denied by the local governing body should not be submitted to the Gambling Control Division. Township: By signature below, the township acknowledges that the organization is applying for a premises permit within township limits. Cft• or County's' City or County Name City of Little Canada Signatue of person receiving appliradon Township'. Title Dam Received Township Name Signature of person receiving applicadon Tide Date Received Person aeuvenng appicanon w some governing way Dare Z T,oiq R1nmhprg I1 /7R /Q1 Is township: ❑Organized ❑Unorganized Refer to the Instructions for the required attachments Mail to: Department of Gaming Gambling Control Division Rosewood Plaza South, 3rd Floor 1711 W. County Road 8 nncau,iIa uu ❑,r11 ❑ Unincorporated Page 7