Agenda - Council - 04/22/2003 - Laserfiche WebLink

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Gambling Site Authorization I hereby consent that local law enforcement officers, the board or agents of the board, or the commissioner of revenue or public safety or agents of the commissioners, may enter the premises to enforce the law. BankRecords Information The board is authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. Organ/zation License Authorization [ hereby authorize the Gambling Control Board to modify the class of organization license to be consistent with the class of permit being applied for. Acknowledgment Oath I declare that: 1. I have read this application and all information submitted to the board is true, accurate, and complete; 2. all other required information has been fully disclosed; 3. I am the chief executive officer of the organ ization; 4. I assume full responsibility for the fair and lawful operation of all activities to be conducted; 5. I will familiarize myself with the laws of Minnesota governing l a~Wul gambling and rules of the board and agree, if licensed, to abide by those laws and rules, including amendments to them; Page 2 of 2 6. any changes in application information will be submitted to the board and local unit of government within ten days of the change; and 7. I understand that failure to provide required informatinnor providing false or misleading information may result in the denial or revocation of the license. Signature of the chief executive officer (Designee may not sign) Date · . Local Unit of Government Ac~owledgment and:Approval Print name ofrcity On behalf of the city, [ hereby acknowledge this application for lawful gambling activity at the premises located within the city's jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to the applying organization. S igh~tur-"-e of city personnel receiving application Title Date I I I For the township: On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling activity within the township limits. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). nt name of township Signature of township official receiving application / / Title Date Pri I I I For the county: On behalf of the county, I hereby acknowledge this application for lawful gambling activity at the premises located within the county's jurisdiction, and that a resolution specifically approving or denying the application will be forwarded to the applying organization. Print name of county Signature of county personnel receiving ap plicafion / / Title Date The information requested on this form (and any attachments) will be used by the Gambling Control Beard (Board) to dethrone your qualifications to be inmlved in lawfid gambling activities in Minnesola. and to assist the Board in conducting a background investigation of yin. You imve the right to refuse to supply the information requested; however, iff you ret'nsc to supply this intbrmation, the Board may not be able to determine your qualifications and, as a cmsequence, may rethse to isme you alicense, if you supply the information requested, the Board will be able to process Your name and address will be public informalmn when received by theBoard. All theother information that you provide will be private data about you until the Beard issuesyonr license. When the Board issues your license, att of the information that you haxe provided to theBoard in the process of spaying tbr your license will become public. IftheBoard does n~ issue you a Ik:ense, all the information you have provided in the process of applying for alicense remains private, with the exception of your name and address which will remain public, Private dataabont you are available only to the tbllowing: Beard members, stnffof tho Beard whose work assignment requires tha~ they have access to the information; the Minncs~a Depar/ment of Public Safety; the Minnesota Attorney General; the Minnesota Commissiomrs of Administration, Finance, and Reveute; the Minnesota Legislative Auditor, national and intermtion~ gambling regulatory agencies; anyone pt~suant to corot order, otherindividuais and agenc/os that are specifically authorized by state ce federal law to haveaccoss to the intbrmation; indiv/duals and agencies let which or legal cedar authorizes a new use or shah ng of informalion nfter this notice was given; and anyone with your wriaen consent. ! I ! I I I