Agenda - Council - 08/28/2001 - Laserfiche WebLink

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LG214 - Premises Permit Application Page 3 of 3 7/01 Local Unit of Government Acknowledgment and Approval If the gambling premises is within city limits, the city must sign this application and provide a resolution. I I I 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. Print name 6f city Signature of city personnel receiving application Title ~' ' ,'~o.~. ~ cDeV: ~ ,¢..~.... Date If the gambling premises is located in a township, both the county and township must sign this application. The county must provide a resolution. For the township On behalf of the township, I acknowledge that the organization is. applying to conduct lawihl gambling activity within the township limits. A to~vnship has no statutory authority to approve or deny an application (Minn. Stat. 349.213, subd. 2). Pdnt name of township Signature of township official acknowledging application Title Date 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 approved or denying the application will be for- warded to the applying organization. Print name of county . Signature of county personnel receiving application Title Date The intbrmation requested on this form (and any premises permit, all of the information that 'you have Ii I I I I .I I I attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a premises permit, ffyou supply the information requested, the Board wilI be able to process your application. This form may require the disclosure of your Social Security number. If so, your Social Security number will be used to determine your compliance with the tax laws of Minnesota. Authorization for requiring your Social Security number is found at 42 U.S.C. 405 (c)(i). Your name and address will be public information when received by the Board. All the other information that you provide will be private data about you until the Board issues your premises permit. When the Board issues your provided to the Board in the process of applying for your premises permit will become public except for your Social Security number, which remains private. If the Board does not issue you a premises permit, all the information you have prokided in the process of applying for a premises permit remains private, with the exception of your name and address which will remain public, Private data about you are available only to the following: Board members, staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota -Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this Notice was given; and anyone with your consent. I I I I I I Questions? Call the Licensing Section of the Gambling Control Board at 651-639-4000. If you use a TTY, you can call the Board by using the Minnesota Relay Service at t-800-627-3529 and ask to place a call to 651-639-4000. This form will be made available in alternative format (i.e. large print, Braille) upon request. -t38-