Agenda - Council - 01/08/2008 - Laserfiche WebLink

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Chief Executive Officer's Acknowledgement and Oath I declare. that: I have read this application and all information submitted to the Board. All information is true, accurate ~nd complete. All other required information 'has been fully disclosed. I am the chief executive officer of the organization. I assume full responsibility for the fair and lawful operation of all gambling activities to be conducted. I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments to them. I certify that the gambling manager is bonded and licensed as required per Minnesota Statutes. . I understand that failure to provide required information or providing false or misleading information may result in denial or revocation of the license. A termination plan will be submitted to the Board within 30 days of termination of our gambling operation. I have' read this application and declare that all information submitted is t ue, accurate, and comple . Date: -/2:J.J.2...J o-'l ..... ............ ~".""" ................................. ';,~~;",~~~.....~....' .:.....L.",:.~,7,,7.. ...~....,.~,.~,.,.... .........: . Mail complete renewal application (all pages), and one check made payable to the State of Minnesota . . . for all renewal fees by: 12/31/2007 to: Gambling Control Board 1711 W Co Rd B #300 S . Roseville, MN 55113 "., . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . Licensing Contact: Email: Phone: Fax #: Kim Larsson kim.larsson@gcb.state.mn.us (651)639-4072 (651) 639-4032 The information requested on this form (and any attachments) Viill be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in'Minnesota, and to assist the Board in conducting a background investigation of you; You have the right to refuse to supply the information requested; however,. if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a license. If you supply -the information requested, the Board will be able to process your application. . Your name and address will be public information when received by the Board. All the other information that you provide will be private data about you until the Board issues your license. When the Board issues your license, all of the information that you have provided to the Board in . the process of applying for your license will become public except for' your Sodal Security number, which remains private. If the Board does not issue you a license, all information you have provided in the process of applying for a license remains private, with the exception of your name and address which will remain public. Private data about you are available only to the follOwing: Board members, Board staff whose work assignment requires that they' have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyonrtpursuant to court order; other individuals and agendes that are specifically authorized by state or federal law to have access to the information; individuals and agendes for which law or legal.order authorizes a new use: or sharing of information after this Notice was given; and anyone with your written consent., Organization Renewal App: Report ",;:,;,:",:".-:~;:c.s;.......",~"..~,.,. :":"--"---"""='~".-:.;.o.t-i'U'.~~~~ry:~,.::.;';.;;:. -83-