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L,G214 <br />Minnesota Lawful Gambling <br />Premise Permit Application - Part 3 <br />C$nowre gement <br />Gambling Site Authorization <br />1 hearby 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 inspect the bank records of the gambling account whenever necessary to fulfill <br />requirements of currant gambling rules and law. <br />I declare that: <br />1 have read this application and all information submitted to the board; <br />All information is true, accurate and complete; <br />Alt other required information has been fully disclosed; <br />I am the chief executive officer of the organization; <br />I assume full responsibility for the fair and lawful gambling and rules of the board and agree. if licensed, <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 board; <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 board 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 />Signature or chief executive officer <br />Oate <br />1/8/91 <br />Lai <br />tvernmeut'at <br />acute <br />1. The city 'must sign if the gambling premises is located within city limits. <br />2. 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 />City or County Name <br />Pity of T,ittla ranada <br />Signature of person receiving application <br />Townships* <br />Signature of person receiving appiieation <br />Titre <br />Dam Received <br />Titre <br />Data Received <br />Person oeevenng appecaeon to Iota) governing way Data <br />3ToAnn M. Sherman 1 /9/9i Is township: [jOrganized ❑Unorganized <br />Refer to tha instructions for the required attachments Mail to: <br />Page 10 <br />Department of Gaming <br />Gambling Control Division <br />Rosewood Plaza South, 3rd Floor <br />1711 W. County Road B <br />Pcssvrlle. MN 95113 <br />❑ Unincorporated <br />