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LG214 <br />Minnasota Lawful Gambling <br />Premise Permit Application - Part 3 <br />owiectgement±1 <br />Gentling Site Authorization • <br />l heathy consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or <br />public safety, or agents of the commissioners, may enter the premises to enforce the law. <br />Bank Records Information <br />The board is authorized to inspe the bank records of the gambling acaiunt whenever necessary to fulfill <br />'requirements of currant gambling rules and law. . <br />declare that: - <br />I have road this application and all information submitted to the board; <br />All information is true, accurate and complete; <br />other required information has been fully credosad; <br />1 am the chief executive officer of the amvanaation; <br />l assume full responsibility for the fair and lawful gambling and rules of the board and agree, if licensed, <br />s.. <br />to abide by those laws and rules, including amendments to them; <br />A membership list of the organization will be available within seven days after it is requested by the beard; <br />Any changes in application information will be submitted to the board and local government within 10 <br />days of the change; and " <br />A termination plan will be submitted to the hoard within 15 days of the termination of all premise permits. <br />Failure to provide required information or providing false information may result in the denial or revocation of the <br />license. <br />kcal Gs3Qraneat Acawe semen. <br />• <br />t. The c3y 'must sign if the gambling premises is located within city limits. <br />a. The county AND township" must sign if the gambling premises is located within a township. <br />. 3. The local government (city or county) must pass a resolution specifically approving or denying the application. , <br />4. A copy of the resolution approving the application must be attached to the application. • <br />5. Applications which are denied by the local governing body should not be submitted to the Gambling Control Division. <br />Township: By signature below, the township acknowledges that the organization is applying for a premises permit within <br />township limits_ <br />City' or County'- <br />Township'* <br />i C Lt I C � r/ It cf /d <br />n recaregA.4licacan <br />U <br />arson del enng appecanon to fool governing oody Date <br />Is tw.nship: [j Cmanized ❑ Unorganized <br />Oats Received <br />Signature at person receiving application <br />Ties <br />Refar to that Inst ucticns for the required attachments Mail to: <br />Department of Gaming <br />Gamciing Control Division <br />Rosewood Plaza South, arc Fc_cr <br />1711 W. County Rosa <br />Oats Received <br />0 Unincorporated <br />