Agenda - Council - 10/25/2005 - Laserfiche WebLink

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LG214 Da~a Privacy The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board)to determine ,~our 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; i~owever, if you refuse to supply ~is information, the Board may not be abIe to determine your qualifications and, as a consequence, may refuse to issue you a premL~es permit. ~f you supply the information requested, the Board wilt be able to process your application. Premises Permit Application This form may require the discJosure of your sodal security number. ]~f so, your soOat security number will be used to determine your compliance with the t~x laws of Minnesota. Authorization for requiring your sodal 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 tine of, her information that you provide wiJl be private data about you until the. Board issues Acknowledgment and Oath Page 2 of 2 8/05 your premises permit. When the Board issues your premises permit, all of the information that you have 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 premise~ permit, all the information you have provided in the process of ap¢lying 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, Board staff: whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Hinnesota Attorney General', the Minnesota Commissioners of Administration, Finance, and Revenue; the Hinnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specJfically authorized by st-ate or federal law to have access to the information; individuals and agencies for which law or iegal order authorizes a new use or sharing of information after this notice was given', and anyone with your consent. 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 Iow. The Board or agents of the board, or the commissioner of revenue or public safety or agents of .the commissioners are authorized to inspect the bank records of the gambling account whenever necessary to fulfill requirements of current gambling rules and law. ! declare that: 1. I have read this application and all information submitted to the Board is true, accurate, and complete; 2. All required information has been fully disclosed; 3. ~ am the chief executive officer of the organization; 4. I assume full responsibility for the fair and lawful operation of all activities to be conducted; - 5. ~ will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if licensed, to abide by those laws and rules, including amendments to them; 6. Any changes in' application information will be submitted to the Board and local unit of government within 10 days of the change; and 7. I understand that failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. .ftLX Signati~r~'of Chief Exe~ive Office?(Designee may not sign) Required Attachments ~ If the premises is leased, attach a copy of your lease, Use form LG2~.5 Lease for Lawful Gambling Activity. 2. Attach the resolution from the local unit of government (city or county) which shows approvat of your application, 3, For each premises permit application, a $:[50 annual premises permit fee is required. Hake the check payaPle to the "State of Hinnesota." Mail ma application with attachments to: GamPling Control Board J. T11 West County Road 8, Suite 300 5outh Roseville, MN 551!3 Date There is a monthly regulatory fee of (.DO:L) of gross receipts from lawful gambling conducted at the site, The fee is reported on the G3. Lawful Gambling Monthly Summary and Tax Return and paid with the monthly tax report. Questions? Call the Ucensing Section oftheGambling Control Board at 651-639-4000. if you use a TTY, call the Board by using the Minnesota Relay Service and ask to place a call to 65:L-639- q000. This form will be made available in alternative format (i.e. large print Braille) u n request -132-