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Minnesota Lawful Gambling I
<br /> Premise Permit APplication - Part 2 of 2
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<br /> Bank Name Bank Account Number
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<br /> Bank Address ' ' / City State Zip Code
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<br /> Name Address Title
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<br />· ali other required infer ' ,_~ ----,
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<br /> Gambling Site
<br /> I hereby consent that local la~ enforcement officers, the
<br /> board or agents of the board, or the commissioner of
<br /> revenue or public safety, or agents of the commissioners,
<br /> may enter the premises to enforce the law,
<br /> Bank Recor~Is Ynf'ormatton
<br /> The board Is authorized to inspect the bank records of the
<br />, gambling account whenever necessary to fulfill '
<br /> requirements of current gambling wles and law.
<br /> Oath
<br /> I declare that:
<br /> · l have read this application and all informalbn submJlled
<br /> to the board is true, accurate and complete;
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<br /> · 1 am the chief executive officer of the organization;
<br /> · I assume full responsibility for the fair and lawful opera-
<br /> tJon of all activities to be conducted;
<br /> · J wJJJ familiarize myself with the laws of Minnesota
<br /> governing lawful gambling and rules of the board and
<br /> agree, if licensed, to abide by those laws and rules,
<br /> including amendments to them; ·
<br /> · any changes in application information will 'be submitted
<br /> to the board and local unit of government w~thin 10 days
<br /> of the change;' and . '
<br /> .....I understand that failure to provide required iniormation
<br /> or providing false or misleading information m.ay result in
<br />.... ' . the denial or revocation of the license.
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<br />1. The city *.must sign this application if the gambling prem-
<br />ises is located within city limits. ·. · '-
<br />2. The coun~ ~*AN.D township;* must sign this apl~caibn [ ..
<br />the gambling premises is located within a township.
<br />3. The local unit government (city or county) must pass a
<br />resolution specifically approving .or denying this applE:at/on.
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<br />4. _A coov of the local ¢~it of qovem.ment'~ resolution ap-
<br />_orovfna this aoolicafion must be atlached to thi~aoolicalion,
<br />5. if this application is denied by the local unit of government,
<br />it should not be submitted to the Gambling Control Board.
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<br />Township: By signature below, the township acknowledges
<br />that the organization is applying for a premises permit within
<br />township I/mits.
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<br />Cindy* or County** ,.. . Township**
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<br />Otb' er County Name
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<br />Signalure of per.s0, n .reqe.(vJng appt~cal~on · ·
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<br />Tide ~ Date Received Date R?c¢ived' :,
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<br />Refer Io tho insl~ucdons fc~ required at~achment~.
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<br /> Township Name
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<br />.. Signature of person receiving application
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<br />to:
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<br />Gambling Conlrol Board
<br />Rosewood Plaza South, 3rd Floor
<br />1711 W. County Road B
<br />Rosovllle, MN 55113
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<br />LG214(Part 2)
<br />(Nov7,~O/9 I)
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