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

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Gambling Site Authorization [ 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. Bank Records 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. Organization License Authorization I 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 l declare that: 1. [ 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. [ 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 lawful 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 informationor prey iding 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 Acknowledgment and Approval ;::~i ' ~ _th~ g~ ~!ing.,~r~!~es i~ ~ith~ ~i~[~imi t~e ici~ m.~i~ im.~ ~!~!~ii~'iaP-c[ ~id~ ~ Print n~e of city ' r~ On behalf of the city, I hereby ac~owledge this application ~_~ ~~~~ for lawful gmbling activity at the premises located within Signature ofciw personnel receiv~g application ~e city's juri~iction, ~d that a resolution specifically ~proving or deny~g the applicafion will be fo~ded to ~~Q~ ~'~C~ ~/ (/ /~ the applying organimtion. 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 Pti I I I For the count'v: On behalf of the county, [ hereby acknowledge this application for lawful gambling activ ity at the premises located w/thin 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 application / / Title Date The information requested on this form (and any attachments) will b0 used by the Gambling Control Bmrd (Board) to de~rmine your qualifications to be invalved in lawful gambling activities in Minnesota, and to assist the Board in condmting a background inmstigat/on of you. You have the right to refuse to supply theinfurmation requested; howexer, if you refuse to supply this/nformation, tie Board may not be able to determine your qualifications and, as a cmsequence, may refuse to issue you a license. If you supply the intbrmation requested, the Board will be able to process Your name and address will be lmblic information when received by the Board. All theother intbrmation 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 tho Board in the process ofap~ying tbr your license will become public. I fthe Board does not issue you a license, all the information you have provided in the process of applying tbr alicense remains private, with the e~eption of your mrne and address which will remain public. Private data abo~t you are available only to the tbllowing: Beard members, stat'fei the Board whosework assignment requires that they have access to the information; the Minnesota Depar~ent of Public S~aty; tho Minnesola Attormy General; the Minnesota Commissiono rs of Adminiatration, Finance, and Revenue; tt'a Minnesota Legislative Auditor, nat/coal and intermtional gambl/ng regulatory agencies; any~e pm'suant to eom order; other individmls and agenc/os that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal ~'der authorizes a new use or sharing of informalion after this notice was given; and anyone with your written consent. I I I I I I