04-09-2014 Council Agenda - Laserfiche WebLink

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L3230 Application to Conduct • ff -site Gambling 5/13 Page 2 of 2 Acknowledgment by Local Unit of Government: Approval by Resolution CITY APPROVAL for a gambling premises located within city limits. COUNTY APPROVAL for a gambling premises located in a township City name Date approved by city council Resolution number (if none, provide meeting minutes) Signature of city personnel Title Date Signed County name Date approved by county board Resolution number (if none, provide meeting minutes) Signature of county personnel Title Date Signed Chief Executive Officer [CEO] Acknowledgment 10. The person signing this application must be your organization's CEO and have their name on file with the Gambling Control Board. If the CEO has changed and the current CEO has not filed a LG200B Organization Officers Affidavit with the Gambling Control Board, he or she must do so at this time. 11. I have read this application, and all information is true, accurate, and complete, and if applicable, agree to the lease terms as stated in this application. CEO signature 12. Print CEO name i/, ,..42%a'/eLFL. 47r Date ,_3___` 2 2 - / G. Daytime phone .. / Mail or fax to: Gambling Control Board 1711 West County Road B, Suite 300 South Roseville, MN 55113 FAX: 651- 639 -4032 No attachments required. This publication will be made available in alternative format (i.e. large print, Braille) upon request. Data privacy notice: The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your organization's qualifications to be involved in lawful gambling activities in Minnesota. Your organization has the right to refuse to supply the Information; however, if your organization refuses to supply this information, the Board may not be able to determine your organization's qualifications and, as a consequence, may refuse to issue a permit. If your organization supplies the information requested, the Board will be able to process your organization's application. Your organization's name and address will be public information when received by the Board. All other information provided will be private data about your organization until the Board issues the permit. When the Board Issues the permit, all information provided will become public. If the Board does not Issue a permit, all information provided remains private, with the exception of your organization's name and address which will remain public. Private data about your organization are available to: Board members, Board staff whose work requires access to the information; Minnesota's Department of Public Safety; Attorney General; Commissioners of Administration, Minnesota Manage- ment & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent.