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06/93/2003 68:26 6514539274
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<br />CLIHB THEATRE
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<br />LG214 Premises Permit Application
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<br />Page 3 of 3
<br /> 7/01
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<br />Local Unit of Government Acknowledgment and Approval
<br />If the gambling premises is within city limits, the city md~t sig? t~i~ application and provi.d, e areso, lution.
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<br />On behalf of the city, I hereby acknowledge this
<br />application for lawful gambling activity at the premises
<br />located within the city's jurisdiction, and that a
<br />resolutiDn specifically approving or denying the
<br />application will be forwarded to the applying
<br />organization.
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<br />Print nem~ a#~ity ¢ . 0
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<br />Signature of: ci~ personnel receiving application
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<br />If the gambling premises is located in a township, both the county and township taus{ sign this applic.~ion.
<br />The county must provide a resolution.
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<br />For thczgpwnshi.p. On behalf of the township, I
<br />acknowledge that the organization Js applying to
<br />conduct lawful gamblLng activity widfin the township
<br />limits.
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<br />A township has no statutory authority to approve or
<br />deny an application (Minn. Stat, 349.213, subd, 2).
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<br />Print r~ame of township
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<br />Signature of township official acknowledging application
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<br />Title Date
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<br />For ~he county On behalf of the county, [ hereby
<br />acknowledgethis application for lawful gambling
<br />activity atthe premises IDeated within the county's
<br />jurisdiction, and that a resolution specifically
<br />approved or denying the application will be for-
<br />warded to the applying organization.
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<br />Print name of county
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<br />Signature of county personnel receiving application
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<br />Title Date
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<br />The information requested en this form (aad any
<br />attachm~nt.~) will bE used by the Gambling Cm~trol Board
<br />~oard) to d~te~¢ y~ ~alifi~ti~s to be invoN~ in
<br />la~l gambling acd~li~s in ~nne~om, an~ ~ assist the
<br />Board in conducllng a ba~ound in~s~ation of~.
<br />You ha~ the right m re,se m supply the inflation
<br />requested; h~ever, if ~ re~se to supply this
<br />info,marion, the Board may not ~ abl~ to dateline ~r
<br />qualificafims and, as a conse~uenc~ may rehse ~ issue
<br />ym a premiszs pe~it, lf~u supply ~e ~mation
<br />r,quested, the Board xxdll ~ able to pm~ss ~ur
<br />application.
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<br />This form may require the disclosure of your Social
<br />S~uurity number. If so, your Social SecuriB, mtmber will
<br />be used ~o d~,rmine your complian** with thc tax law~ of
<br />Minnesota. Authorization for requiring your 8o¢ial
<br />Security number is fmmd at 42 U.S.C. 405 (c)(i).
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<br />Your name and address will be public infornmtion when
<br />recdved by th, Board. All the oth~r bformation that you
<br />provide will be private data about you until thc Board issues
<br />your prembes permit. When the Board lames your
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<br />premises purmit, ali of thc infr~'matirm that you have
<br />provided to the Board in the process of applying for your
<br />premises profit w/ll become public except for your Social
<br />Security number, which remains private. If th, Board do, s
<br />not issue you a premises p,rmit, all the information y~u
<br />hay= prodded in the process o.f applying for a premises
<br />permit r,maaius privatc, with the r, xcq~tion of your nam~
<br />and address which v, dll tcrnaia public.
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<br />Pdvat~ data about you are available only to the following:
<br />Board member8, ~taffofthe Board whose work asaignment
<br />requires that they have access to the ~fotmatio~; th~
<br />Mirmesota Department of Public Safety; thc Mirtaesota
<br />Attorney Central; the Minnesota Commissioners of
<br />Administration, Firtance, and Revenue; the Minnesota
<br />LegL*lative Auditor, nat/chat attd international gambling
<br />regulatory agencies; anyone pursuant to court order; oth~r
<br />indi¼duals and agertc[es that are ~p~eifical[y ~uthorized by
<br />atat¢ or federal law to ham access to the information;
<br />individuals and agra*ice for which law or legal order
<br />authorize8 a n,w use or sharing of hnformatiun after this
<br />Notic, was given; and anyone with your consent.
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<br />Questions? Call the Licensing Section of the Gambling Control Board, at 651,639-4000. If you tt~¢ a TTY, you can call
<br />the Bmrd byusing the MJnrtc,ora l~tay Sc, trice and ask to plat* a call to 651-639-4000. Thi~ form xvill be made available
<br />alt, crnative f'on~at (i.e. large prim, Braille) upon requ,~t.
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