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. 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 cons[stent 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 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 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 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 appro ring or denying the application will be forwarded to the applying organization. Local Unit of Government Acknowledgment and Approva! Print name of city Signature of city personnel receiving application Title Date For the township: On behalf of the township, [ 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 counts,: On behalf of the county, (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 application / / Title Date The info~mation requested on this form (and any attachments) will ke used by the Gambling Control Board(Board) to determine your qualifications to he involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background inmstigation of you. You ~'~ the right to refuse to supply the information requested; however, if you refuse to supply th/s information, the Board may not be able to determine your qualifications and, as aconsequence, may refuse to isme you a license, lfyou supply the inlbrmafion requested, tho Board will be aNe to process _._y§t~_application. Your name and address will be public information when received by the Board. All the other information fl~at you provide will be private data aboutyou until the Bmrd ismes your license. When ~he Board issues your license, all of the information that you have provided to the Board in the process ofapp{ying £or your license will become punic. IftheBoard does no~ issueyou a license, all the information you have g'ovided in the process of applying for alicense remains private, with the exception of your name and address which will remain public. Private dataabc~t you are available only to the following: Board members, staff of the Board whose work assignment requires that they have a~cess to the information; the Minmsota Department of Public Safer% the Minnesota Attc~ncy General; the Minnesota Corem issionorx of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and internaOonal gambling regulatory agencies; anyone pursuant to cot~t order;, other individmls and agencies that are specifically authorized by state or federal law to ~ave access to the intbrmation; individuals and agencies for which law orlagal a'der aulhonzes anew useor shar/ng of information al'tar this notice was given; and anyone with your wriaen consent. I I I I I I