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Minnesota Lawful Gambling
<br />Premise Permit Application - Part 2 of 2
<br />• 3
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<br />Bank Address City State Zip Code
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<br />Aka Iecigement
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<br />Gambling Site Authorization
<br />I hereby consent that focal law enforcement officers, the
<br />board or agents of the board, or the commissioner of
<br />revenue or public safety, or agents of the commissioners,
<br />may enter the premises to enforce the law.
<br />Bank Records Information
<br />The board is authorized to inspect the bank records of the
<br />gambling account whenever necessary to fulfill
<br />requirements of current gambling rules and law.
<br />Oath
<br />I declare that:
<br />•I have read this application and all information submitted
<br />to the board is true, accurate and complete;
<br />.all other required information has been fully disclosed;
<br />..
<br />�4ij5+�`4s::•
<br />}ss
<br />• I am the chief executive officer of the organization;
<br />• I assume full responsibility for the fair and lawful opera-
<br />tion of all activities to be conducted;
<br />.1 will familiarize myself with the laws of Minnesota
<br />governing lawful gambling and rules of the board and
<br />agree, if licensed, to abide by those laws and rules,
<br />including amendments to them;
<br />-any .changes in application information will be submitted
<br />to the board and local unit of government within 10 days
<br />of the change; and
<br />.1 understand that failure to provide required information
<br />or providing false or misleading information may result in
<br />the denial or revocation of the license.
<br />Signature of chief executive officer
<br />Date
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<br />1. The city *must sign this application if the gambling prem-
<br />ises is located within city limits.
<br />2. The county "AND township** must sign this application if
<br />the gambling premises is located within a township.
<br />3. The local unit government (city or county) must pass a
<br />resolution specifically approving or denying this application.
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<br />4. A coov of the local unit of oovernment's resolution ap-
<br />proving this application must be attached to this application..
<br />5. If this application is denied by the local unit of, government,
<br />it should not be submitted to the Gambling Control Board.
<br />Township: By signature below, the township acknowledges
<br />that the organization is applying for a premises permit within
<br />township limits.
<br />City' or County**
<br />City or County Name
<br />Signature 4-per ftSn receiving applies on
<br />�C� 9
<br />Tide
<br />Township..
<br />Township Name
<br />Signature of person receiving application
<br />Date Received
<br />8/ia /qg
<br />Refer to the instructions tor required attachments.
<br />Mail to:
<br />Gambling Control Board
<br />Rosewood Plaza South, 3rd Floor
<br />1711 W. County Road B
<br />Roseville, MN 55113
<br />Title Date Received
<br />LG214(Part 2)
<br />(R.vlrzav 1)
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