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

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Gambling Site A uthorization 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. BankRecards 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 [ 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 fuJly 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 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 ap~ormation 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 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 Acknowledgment and 6pproval :~: If the g~.bl[ng:premises ~ ~vithin:¢ i~[ ~its ;.:Stheci ty.mm s[:~ this a P P4! e a iff~ h ~¢~6 ~[~ ~a~ ~!g} Print name otLcity ~ S~gnature of tory p~rsonnel receiving On behalf of the city, I 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. Title Date ! I I I I i I I I For the township: On behalf of the township, I acknowledge that the organization is applying to conduct lawful gambling activity w/thin the township limits. A township has no statutory authority to approve or deny an application (iVfinn. Stat. sec. 349.213, subd. 2). nt name of township Signature of township official receiving application / / Title Date .For the county: On behalf of the county, I hereby Pti I I I 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 application / / Title Date The ifformation requested on this form (and any attachments) will ~ used by the Gambling Control Bmrd (Board) to determine your quatifications to be inx~lved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of yin. You ha~e the right to refuse to sul:ply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as aconsequence, may mi'use to issue you a license. If you supply the intbrma~on requested, the Board will be alJ. e to process :p,i ation. Your name and address will be lmblic information when received by theBoard. All theother information ~at you provide wlil be private data aboutyou until the Boardissues your license. When the Board issues your license, ali of the/ntbrmatiou that you ha~e provided to the Board in the process ofapldy/ng tbr yourlJcense will kecome public. IftheBoard does notissueyou a license, all the intbrmation you have ixovided in the process of applying for a license remains pr/rate, with ~heexccption o£your name ,'md address whioh will remain public. Private data about you are availatJe only to the tbllowing: Board mam~rs, s~affof the Board whose work assignment requires that they have access to the information; the Minmsota Department of Public Safety; the Minnesota Attormy General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislatim Auditor, national and internat/onal gambling regulatory agenaies; anyone ptrsmnt to corot order;, other individuals and agencies that are specifically anther[zed by state or federal law to have access to the intbrmation; hdividuals and agencies for which law or legal order authorizes anew useor sharing of int'ormation after this notice was given; and anyone with your written consora. I I I I I I