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Acknowledgment Page 2 of 2 rhereby ng Site Authorization Oath 6. any changes in application information consent that local law enforcement I declare that: will be submitted to the board and local the board or agents of the board,or 1. I have read this application and al l unit of government within ten days of missioner of revenue or information submitted to the board is true,afety or agents of the accurate, and complete; the change;and 7. I understand that failure to provide commissioners,may enter the premises to 2. all other required information has been required information or providing false or enforce the law. fully disclosed; Bank Records Information 3. I am the chief executive officer of the misleading information may result in the The board is authorized to inspect the bank organization; denial or revocation of the license. records of the gambling account whenever 4. I assume full responsibility for the fair and necessary to fulfill requirements of current lawful operation of all activities to be gambling rules and law. conducted; Organization License Authorization 5. 1 will familiarize myself with the laws of Signature of the chief executive I hereby authorize the Gambling Control Minnesota governing lawful gambling and officer(Designee may not sign) Board to modify the class of organization rules of the board and agree,if licensed,to license to be consistent with the class of abide by those laws and rules,including permit being applied for. amendments to them; Date Local Unit of Government Acknowledgment and Approval �Tf a ganibtwg prertuses is w to ctty tmtts, a ctty must stgn tfiis app coon an"dprov-e atd'�rw utton On behalf of the city,I hereby acknowledge this application for lawful gambling activity at the premises located within Print name of city the city's jurisdiction,and that a resolution specifically approving or denying the application will be forwarded to Signature of city personnel receiving application the applying organization. Title Date If the ganili]ing premisesisl"orated in atownship;-both the county and township-musf:sign-this-applicatioa -- -�— `— The county must provide a'resolution. For the township:On behalf of the township,I acknowledge that the organization is applying to conduct lawful gambling Print name of township activity within the township limits. A township has no statutory authority to approve or deny an Signature of township official receiving application application(Minn.Stat.sec.349.213,subd.2). Title Date For the county:On behalf of the county,I hereby acknowledge this application for lawful gambling activity at print name of county the premises located within the county's jurisdiction,and that a resolution specifically approving or denying the Signature of county personnel receiving application application will be forwarded to the applying organization. Title Date The information requested on this form(and Your name and address will be public Board whose work assignment requires that any attachments)will be used by the information when received by the Board. All they have access to the information;the Gambling Control Board(Board)to the other information that you provide will Minnesota Department of Public Safety; determine your qualifications to be involved be private data about you until the Board the Minnesota Attorney General; the in lawful gambling activities in Minnesota, issues your license. When the Board issues Minnesota Commissioners of and to assist the Board in conducting a your license,all of the information that you Administration,Finance,and Revenue;the background investigation of you. You have have provided to the Board in the process of Minnesota Legislative Auditor, national the right to refuse to supply the information applying for your license will become and international gambling regulatory requested;however,if you refuse to supply public. If the Board does not issue you a agencies;anyone pursuant to court order; this information,the Board may not be able license,all the information you have other individuals and agencies that are to determine your qualifications and,as a provided in the process of applying for a specifically authorized by state or federal consequence,may refine to issue you a license remains private,with the exception law to have access to the information; license. If you supply the information of your name and address which will remain individuals and agencies for which law or requested,the Board will be able to process public. legal order authorizes a new use or sharing your application. of information after this notice was given; Private data about you are available only to and anyone with your written consent. • the following: Board members,staff of the