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Acknowledgment Page 2 of 2 <br /> Gambling Site Authorization Oath 6. any changes in application information • <br /> I hereby consent that local law enforcement I declare that: will be submitted to the board and local <br /> officers,the board or agents of the board,or 1. I have read this application and all unit of government within ten days of <br /> the commissioner of revenue or information submitted to the board is true, the change;and <br /> public safety or agents of the accurate, and complete; 7. I understand that failure to provide <br /> commissioners,may enter the premises to 2. all other required information has been required infonnation or providing false or <br /> enforce the law. fully disclosed; misleading information may result in the <br /> Bank Records Information 3. I am the chief executive officer of the denial or revocation of the license. <br /> The board is authorized to inspect the bank organization; <br /> records of the gambling account whenever 4. I assume full responsibility for the fair and <br /> necessary to fulfill requirements of current lawful operation of all activities to be <br /> gambling rules and law. conducted; <br /> Organization License Authorization 5. I will familiarize myself with the laws of Signature of the chief executive <br /> I hereby authorize the Gambling Control Minnesota governing lawful gambling and officer(Designee may not sign) <br /> Board to modify the class of organization rules of the board and agree,if licensed,to <br /> license to be consistent with the class of abide by those laws and rules,including <br /> permit being applied for. amendments to them; Date <br /> Local Unit of <br /> IfthexgainbGovernment Acknowledgment and Approval <br /> 44 stwithdc ds cit � atsiad, ide� r <br /> ,yugr tixe <br /> On behalf of the city,I hereby acknowledge this application City of St. Anthony <br /> for lawful gambling activity at the premises located within Pri t e of ity <br /> the city's jurisdiction,and that a resolution specifically <br /> approving or denying the application will be forwarded to <br /> the applying organization. ignature o city personnel receiving plication <br /> City Manager 01 / 22 102 <br /> Title Date <br /> =��MIf�thegamliling�preinises,islocated� '�a,tiiwnstiip,both'tfieaouitty��d>towttstiipmiist:'sign,tliisapplication:P< ��� �°''a. <br /> 'thew riutty mit9ty". 3ies0lo�n v <br /> For the township:On behalf of the township,I acknowledge <br /> that the organization is applying to conduct lawful gambling Print name of township <br /> activity within the township limits. <br /> A township has no statutory authority to approve or deny an Signature of township official receiving application <br /> application(Minn. Stat sec.349.213,subd.2). <br /> Tide Date <br /> For the county:On behalf of the county,I hereby <br /> acknowledge this application for lawful gambling activity at Print name of county <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 the applying organization. Signature of county personnel receiving application <br /> Title Date <br /> The information requested on this form(and Your name and address will be public Board whose work assignment requires <br /> any attachments)will be used by the information when received by the Board. that they have access to the information; <br /> Gambling Control Board(Board)to All the other information that you provide the Minnesota Department of Public <br /> determine your qualifications to be involved will be private data about you until the Safety;the Minnesota Attorney General; <br /> in lawful gambling activities in Minnesota, Board issues your license. When the Board the Minnesota Commissioners of <br /> and to assist the Board in conducting a issues your license,all of the information Administration,Finance,and Revenue;the <br /> background investigation of you. You have that you have provided to the Board in the Minnesota Legislative Auditor, national <br /> the right to refuse to supply the information process of applying for your license will and international gambling regulatory <br /> requested;however,if you refuse to supply become public. If the Board does not issue agencies;anyone pursuant to court order, <br /> this information,the Board may not be able you a license,all the information you have other individuals and agencies that are <br /> to determine your qualifications and,as a provided in the process of applying for a specifically authorized by state or federal <br /> consequence,may refuse tq issµe you a license remains pnvate,with the exception law to have access to the information; • <br /> license. If you supply the information of your name and address which will remain individuals and agencies for which law or <br /> requested,the Board will be able to process public. <br /> your application. <br /> Private data about you are available only to <br />