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01/27/2003 13:29
<br />6517668351
<br />Comb ling Site A utttorixation
<br />I hereby consent that local law e boa de or
<br />officers. the board or agents
<br />the commissioner ofrevenue eor
<br />public safety or agents enter the premises to
<br />commissioners, may
<br />enforce the law.
<br />Baal: Records Informatioo the bank
<br />The board is authori zed to an inspect u t the bank
<br />records of the gambling
<br />necessary to fulfill requirements of currant
<br />gambling rules and law.
<br />thorization I hereby authorize the Gambling Control
<br />Board to modify the class of organization
<br />REC SPORTS & PLAY
<br />Acknnwled' menu
<br />PAGE 03
<br />c2af2
<br />6. any changes in appl imtion information
<br />Oath will be submitted to the board and local • 1 declare
<br />that: unit of government within ten days of
<br />1 I have read ad this application and all the change; nge•, and
<br />information submitted to the board is true, 7 I e thatfailure to provide
<br />accurate, and complete; required information or providing false or
<br />misleading information may result in rho
<br />denial or revocation of the license.
<br />2. all other required information has been
<br />fully disclosed;
<br />3. 1 am the chief executive officer of the
<br />organization;
<br />4. I assume full responsibility for the fair and •
<br />lawful operation of all activities to be .
<br />conducted;
<br />5. I will familiarize myself with the laws of
<br />Minnesota governing lawful gambling and
<br />rules of the board and agree, if licensed, to
<br />. .• . - i •
<br />permit being applied for. j 1 .G rn ert ti
<br />ed gnentand q. . �.
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<br />0n behalf of the city,1 hereby acknowledge this application
<br />for lawful gambling activity at the premises located within
<br />the city's jurisdiction, and that a resolution sp e Y
<br />approving or denying the application will bc forwarded to
<br />the aovlyine orean',zauon-
<br />.r
<br />Signature of the chief executive
<br />officer (Designee may not sign)
<br />Date
<br />•
<br />Print name of city
<br />S ibnamre of city personnel receiving application
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<br />Fe r t On behalf of the township, I acknowledge
<br />that the organization is applying to conduct lawful gambling
<br />activity within the township limits.
<br />A township has no statutory authority to approve or deny an
<br />application (Minn. Stat. sec. 349.213, subd. 2).
<br />For the county: On behalf of the county, thereby
<br />acknowledge this application for lawful gambling activity at
<br />the premises located within the county's jurisdiction, and
<br />that a resolution specifically approving or denying the
<br />application will be forwarded to die applying organization.
<br />'Mc information requested on this form (and
<br />any attachments) will be used by the
<br />G rimbl ing Control Board (Board) to
<br />determine your qualifications to be involved
<br />in lawful gambling activities in Minnesota,
<br />and to assist the Board in conducting a
<br />background investigation of you. You have
<br />the right to refuse to supply the information
<br />requested; however, if you refuse to supply
<br />this information, the Board may not be able to
<br />determine your qualifications and, as a
<br />consequence, may refuse to issue you a •
<br />Print name of township
<br />Signature of township official receiving application
<br />Print name of county
<br />Signature of county personnel receiving application
<br />/ • /
<br />•rule
<br />Your name and address will bc public
<br />information when received by the Board. AU
<br />the other information that you provide will
<br />be private data about you until the Board
<br />issues your license. When the Board issues
<br />your licensc, all of the information that you
<br />have provided to the Board in the process of
<br />applying for your license will become public.
<br />lithe Board does not issue you a license, all
<br />the information you have provided in the
<br />process of ap plying fora license remains
<br />private, with the exception of your name and
<br />address which will remain public.
<br />1' PP
<br />Board whose work assignment requires that
<br />they have access to the information; the
<br />Minnesota Depart meat of Public Safety;
<br />the Minnesota Attorney General; the
<br />Minnesota Commissioners of
<br />Administration, Finance, and Revenue; the
<br />Minnesota Legislative Auditor, national
<br />and international gambling regulatory
<br />agencies, anyone pursuant to court order;
<br />other individuals and agencies that are
<br />specifically authorized by state or federal
<br />
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