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<br />OCT-28-2003 15:20 FROM:MRRY RUE SCHUTTR CPA 7637841729
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<br />10:551 483 8520
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<br />P.004
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<br />, 'A~kn~wled~~merit an~;,qath: :: ,:::: ..
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<br />[ DECLA.RE THAT:
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<br />I have read this application and all information
<br />submitted to the Gambling Control Board;
<br />All the information is true, accurate and complete;
<br />All 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
<br />operation of all gambling activities to be conducted;
<br />I will familiarize myself with the laws of Minnesota
<br />governing gambling and rules of the Gambling Control
<br />Board and agree, if to abide by those laws and rules,
<br />including amendments to them;
<br />Any changes in application information will be submitted
<br />to the Gambling Control Board within 10 days of the
<br />change;
<br />I understand that failure to provide required information
<br />or providing false or misleading Information may result
<br />in denial or revocation of the license.
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<br />I have read this application and dcdare that all information
<br />submitted is true, accurate, and complete.
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<br />Notary Public Seal must be current and correct; seal may
<br />not be altered. Subscribed rmd sworn to before me this
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<br />
<br />-"ww RUE SCHUITA
<br />NOTARY PUBLIC. MINNeSOTA
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<br />-'. .............
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<br />Mail comolete renewal aoolication by: 12/2(2003
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<br />to:
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<br />I':~,on~~cil ~~~rd::I.711. W'Co Rd B :
<br />"",~30~~~~()$ieville, MN SSl13. \
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<br />OrQanization license
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<br />1816
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<br />licensing Contact:
<br />Phone:
<br />Fax #
<br />Email:
<br />
<br />Roxie Rolph
<br />(651) 639-4079
<br />(651) 639-4073
<br />roxie. rol ph@gcb.state.mn.us
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<br />< :~;~:/ The infonnation requested on this form (and any attachmen~) will be used by the Gambllng Control Board (Board) b:J determine your
<br />,.~':" 1i~;", Qualifications to be Involved In lawful gambling activities In r-1innesota, and to assist the Board in conductIng a background investi~i:ltlon of
<br />~,. ",:;:!( you. You have the right to refuse to supply \he Information requested; however, If you refuse In supply this informaUon, the Board mi!lY
<br />r"i :i;/:ji, not be able to detennine your qualifications and, as a consequence, may refuse to Issue you a license. If you supply the Information
<br />i, :; ::,' :< 7:; ~ requested, the Board will be able to pro~ess your application,
<br />'~, , :'~ oJ': Your name and address will be public Information when received by the Board. All the ctJ1er information that you provide will be prl~te
<br />',' " ?, .:. ; data about you until the Board issues your license. When the Board iSSUes your license, an of the information that you haye provided to
<br /><, ' " '. ;<;.~; the Board in the process of applying for your license will bewme pUblic except for your Social Security number, which reml'lins priYalle, If
<br />;;;':: ";.:< the Board does not Issue you a license, afllnformation you have provIded In the process of applying for a license remains prIvate, wIth the
<br />.. : ';)';-:: Cl:ceptlon of your name and address which will remain public,
<br />0' y,>:,.:. T Private data about you are available only to the following: Board members, staff of the f3.:;lGlrd whose work assignment requires that they
<br /><,,.~; \':: have access In the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota
<br />:';'" ;..j,;' Commissioners of Administration, Finance, and Revenue; the Mlnnesata Legislative Auditor, national and International gtlmbling regul~tory
<br />:':,',: ", L ,( agencies; anyone pursuant In court order; other individuals and agendes that are specifically authorizeCl by st'Ite or federal law to have
<br />, ' ",~,,:,. a:cess In the information; individuals and agencies for which law or legal order C1UthOriZes a new use or sharing of informatIon all:er this
<br />" ::' Notice wes given; and anyone with your written consent
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