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LG214 Premises Permit Application <br />Data Privacy <br />The information requested on this form (and any attachments) <br />will be used by the Gambling Control Board (Board) to <br />determine your qualifications to be involved in lawful gambling <br />activities in Minnesota, and to assist the Board in conducting a <br />background investigation of you. You have the right to refuse <br />to supply the information requested; however, if you refuse to <br />supply this information, the Board may not be able to • <br />determine your qualifications and, as a consequence, may <br />refuse to issue you a premises permit. If you supply the <br />information requested, the Board will be able to process your <br />application. <br />Your name and address will be public information when <br />received by the Board. All other information you provide will <br />be private data until the Board issues your premises permit. <br />When the Board issues your premises permit, all permit information <br />provided will become public. If the Board does not issue you a <br />premises permit, all the information provided remains private, with <br />the exception of your name and address that will remain public. <br />Private data about you are available to: Board members; Board <br />staff whose work requires access to the information; Minnesota's <br />Department of Public Safety; Attorney General; Commissioners of <br />Administration, Finance, and Revenue; Legislative Auditor; national <br />and international gambling regulatory agencies; anyone pursuant to <br />court order; other individuals and agencies that are specifically <br />authorized by state or federal law to have access to the <br />information; individuals and agencies for which law or legal order <br />authorizes a new use or sharing of information after this notice <br />was given; and anyone with your consent. <br />Acknowledgment and Oath <br />1. I hereby consent that local law enforcement officers, the Board or its agents, and the commissioners of revenue or <br />public safety and their agents may enter the premises to inspect it and enforce the law. <br />2 <br />ins e t the e bank records of th gambling ng account whenever necessary to fulfill requirements authorized <br />and public safety and their agents <br />ments of curr current gambling <br />g <br />P <br />rules and law. <br />3. I have read this application and all information submitted to the Board is true, accurate, and complete. <br />4. All required information has been fully disclosed. <br />5. I am the chief executive officer of the organization. <br />6. I assume full responsibility for the fair and lawful operation of all activities to be conducted. <br />7. I will familiarize myself with the laws of Minnesota governing lawful gambling and rules of the Board and agree, if <br />licensed, to abide by those laws and rules, including amendments to them. <br />8. Any changes in application information will be submitted to the Board no later than 10 days after the change has <br />taken effect. <br />9. I understand that failure. to- provide <br />the denial or revoc t n •b <br />Pyin name <br />S�+g f thief Ex`ecutiv cer (designee may not sign) <br />'ire' ' • ocr�ation or providing false or misleading information may result in <br />P E G - f 4 te -1 2) <br />Application and Required Attachments <br />1 LG214 Premises Permit Application <br />2. If the premises is le ed, attach a copy of your. lease. <br />Use LG215 Lease for `.awful Gambling Activity. <br />3. Attach a resolution from the local unit of government that <br />shows approval of your application: <br />• if the premises is within a city, attach city approval, or <br />• if the premises is within a township, attach county <br />approval: <br />4. $150 annual premises permit fee, for each permit. <br />Make check payable to "State of Minnesota." <br />Mail to: <br />Gambling Control Board <br />1711 West County Road B, Suite 300 South <br />Roseville, MN 55113 <br />Monthly Regulatory Fee <br />If you receive a premises permit for this site, <br />there is a monthly regulatory fee of 0.1% (.001) <br />of gross receipts from lawful gambling <br />conducted at the site. The fee is reported on the <br />G1 Lawful Gambling Monthly Summary and Tax <br />Return and paid with the monthly tax report. <br />Questions? <br />Call the Licensing Section of the Gambling <br />Control Board at 651- 639 -4000. <br />This form will be made available in alternative <br />format (i.e. large print, Braille) upon request. <br />6/07 <br />Page 2 of 2 <br />