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LG214 Premises Permit Application 6/15 Page 2 of 2 ACKNOWLEDGMENT BY LOCAL UNIT OF GOVERNMENT: APPROVAL BY RESOLUTION City Name: Date Approved Resolution (If none, Signature CITY APPROVAL for a gambling premises located within city limits t =. COUNTY APPROVAL for a gambling premises located in a township County Name: by City Council: Date Approved by County Board: Number: Resolution Number: attach meeting minutes.) of City Personnel: (If none, attach meeting minutes.) Signature of County Personnel: Title: Date Signed: Title: Date Signed: TOWNSHIP NAME: Local unit of government must sign. Complete below only if required by the county. On behalf of the township, I acknowledge that the organization is applying to conduct gambling activity within the township limits. (A township has no statutory authority to approve or deny an application, per Minnesota Statutes 349.213, Subd. 2.) Print Township Name: Signature of Township Officer: Title: Date Signed: ACKNOWLEDGMENT AND OATH 1. I hereby the Board revenue and inspect 2. The revenue authorized account current 3. I have submitted 4. All required 5. I am consent that local law enforcement officers, or its agents, and the commissioners or public safety and their agents may the premises. Board and its agents, and the commissioners and public safety and their agents, are to inspect the bank records of the gambling whenever necessary to fulfill requirements gambling rules and law. read this application and all information to the Board is true, accurate, and complete. information has been fully disclosed. the chief executive officer of the organization. 6. I assume full responsibility for the fair and lawful operation of of all activities to be conducted. enter I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if licensed, of to abide by those laws and rules, including amendments to them. of 8. Any changes in application information will be submitted to the Board no later than ten days after the change has taken effect. 9. I understand that failure to provide required information or providing false or misleading information may result in the ' denial or revocation of the license. 10. I understand the fee is non-refundable regardless of license approval/denial. 5/1 3/1 9 --.r Signature of Chief Executive Officer (designee may not sign) Date Data privacy notice: The information requested on this information when received by the Board. Minnesota's Department of Public Safety, form (and any attachments) will be used by the All other information provided will be Attorney General, Commissioners of Gambling Control Board (Board) to determine your private data about your organization until Administration, Minnesota Management & organization's qualifications to be involved in lawful the Board issues the permit. When the Budget, and Revenue; Legislative Auditor, gambling activities in Minnesota. Yourorganization has Board issues the permit, all information national and international gambling the right to refuse to supply the information; however, provided will become public. If the Board regulatory agencies; anyone pursuant to If your organization refuses to supply this information, does not issue a permit, all Information court order; other individuals and agencies the Board may not be able to determine your provided remains private, with the specifically authorized by state or federal law organization's qualifications and, as a consequence, exception of your organization's name and to have access to the information; individuals may refuse to issue a permit. If your organization address,which will remain public. Private and agencies for which law or legal order supplies the information requested, the Board will be data about your organization are available authorizes a new use or sharing of able to process your organization's application. Your to: Board members, Board staff whose Information after this notice was given; and organization's name and address will be public work requires access to the information; anyone with your written consent. This form will be made available in alternative format, i.e. large print, braille, upon request. An equal opportunity employer