Agenda - Council - 11/13/2001 - Laserfiche WebLink

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Acknowledgment Page 2 of 2 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 Auth0rizatio n I hereby authorize the Gambling Control Board to modi~ the class of organization license to be consistent with the class of permit being applied tbr. Oath I declare that: 1. I have read this application and all intbrmation submitted to the board is true, accurate, and complete; 2. all other required information has been fully disclosed; 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 information or providing false or misleading information may result in the 3. [ am the chief executive officer of the denial or revocation of thc license. organization; 4. I assume full responsibility for the fair and .~---'~" ...~~~-"~ lawful operation of a I activities to be conducted; .................. ~ ~-~fi~fe ol~he chief executive 5. I Will IallllllarlZ¢ myselrw~m tne taw~~.,~2.7 . . Mi~esom govem~g lawful gamb~' officer ~ may not s~) roles of~e ~d and a~ee, ifli~d, ~ide by ~ose laws ~d ml~, includ~gme~tL/ ~7 ' t 2 / ~endments to ~em; Local Unit of Government Acknowledgment and ApprovaL On behalf of the city, I hereby acknowledge this application fbr 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"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 lawtid gambling Print name of township activity within the township limits. A township has no statutory authority to approve or deny an application (Minn. Stat. sec. 349.213, subd. 2). Signature of township official receiving application / / Title Date For the county: On behalf of thc county, I hereby acknowledge this application tbr [awful gambling activity at the premises located within the county's jurisdiction, and that a resolution specifically approving or denying the application will be tbrwarded to the applying organization. Print name of county Signature of county personnel receiving application / / Title Date Thc intbrmation requested on this tbrm (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gtunbling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the infbrmation requested; however, if you refuse to supply this infbrmation, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a license, if you supply the inlbrmation requested, file Board wi 11 be ab le to process your application. 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 license. When the Board issues your license, all of the information that you have provided to the Board in the process of applying for your license will become public. If the Board does not issue 7ou a license, all the information you have provided in the process of applying for a license remains private, with the exception of your name and address which will remain pubt lc. Private data about you are available only to the following: Board members, staffofthe Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesfta C omm issioners 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 -121-