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Minn~ota Ix~ofuI Gam~Iing i Premise Permit Application - Part 2 of 2 Bank Name [ ~ Account Number nk Acl0ress ~ City State Zip 'G~mb~g S[[~ ~~o= -I am the chiet executive oilier el the organa~tion; I hereby ~nsent that ~ law enfo~ment offi~rs, the -1 assume full res~nsibili~ tot the fair and la~ul o~ra- board or agents c~f the l)oard, or the commissioner of revenue or public satel~', or agents of the commissioners, may enter the premise~ to eniorce the taw. ]Sank Recoras l~fl~. 1-~afl0II The board is authorizeri to inspect the bank records of the gambling accounl whe~ever necessary to lulfill requirements of current~, gambling rules and law. Oath I declare that: · I have read this application and all information submitted to the board is true, accurate and complete; . . · alt other reo. uired infon ~ation'has-,b~en f_~uliy disclosed; tion of all activities to be conducted; · I will familiarize myself with the laws of Minnesota governing lav~ul gambling and rules of the board and agree, if licensed, to abide by those laws and rutes, including amendments lo them; · any changes in application intormation wilJ be submilled to the board and local unit of government within 10 days of the change; and · i understand that failure to provide required iniormation or providing false or misleading iniormalion may result m · the denial or revocation of the license. 4. A coov of the local unil Of oovernmen~,'~ re.?,olulion on)vino this application mu$'( be attached to this application, 5. If this application is denied by' the local unit of government, it should not be submitted to the Gambling Control Board. Signature.of i. The city 'must sign tl~is applioa~ion if the gambling prem- ises ~ to~ed wbhin ~ limbs ....... 2. The ~un~ '*AND t~wnship~' mua sign this ~plicaticn E the gambling premises ~ ~l~ w~hin a t~wnship. 3. The bcal un~ goverhment (c~ or ~un~) must p~s a resolution sp~Ei~lly ~rovi~ or denying this ~pl~ation. Township: By signature below, the township acknowledges that the organization is appiying for a premises permit within township limits. City' or Count¥"~ City or County Name ('"~L ~._..~ c-y-~.' C~ ~--,~ ._c-~--~-7 _~ _,. SiDna~re ~e[~9n m~.i~g appi~n -~. '..' . ' . - .- .. Reter ~ ~e ins~ons I~ui~ M~I to: Gambling ~n~ol B~rd Ro~w~ P~ ~, 3rd ~oor 1711 W. ~un~ Road ~ Rosevllla, MN ~113 Township" Township Name _..Signature of person receiving application Tide ' ' I Date Received. LG214(Part 2) (RevT/"ZgG'I) ,46