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Acknowledgment Page 2 of 2 Gambling Site Authorization Oath 6. any changes in application information I hereby consent that local law enforcement I declare that: will be submitted to the board and local — officers,the board or agents of the board,or 1. I have read this application and all unit of government within ten days of the commissioner of revenue or information submitted to the board is true, the change; and public safety or agents of the accurate, and complete; 7. I understand that failure to provide commissioners,may enter the premises to 2. all other required information has been required information or providing false or enforce the law. fully disclosed; misleading information may result in the Bank Records Information 3. I am the chief executive officer of the denial or revocation of the license. The board is authorized to inspect the bank organization; records of the gambling account whenever 4. I assume full responsibility for the fair and necessary to fulfill requirements of current lawful operation of all activities to be gambling rules and law. conducted; Organization License Authorization 5. I will familiarize myself with the laws of Signature of the chief executive I hereby authorize the Gambling Control Minnesota governing lawful gambling and officer(Designee may not sign) Board to modify the class of organization rules of the board and agree,if licensed,to license to be consistent with the class of abide by those laws and rules,including permit being applied for. amendments to them; Date Local Unit of Government Acknowled+ment and Approval brrtg o + = =pzav iiie a resolution On behalf of the city,I hereby acknowledge this application City of Peq+'^} Takes for lawful gambling activity at the premises located within Print name of city the city's jurisdiction,and that a resolution specifically approving or denying the application will be forwarded to ''� • �1- the applying organization. Signatur f city per • e receiving application City C]erk 0&J 2 02 y Title Date 4 3:t t iE 76:74).f` & •W 3 .4 4 !, 3W +�Q 1! £ ro3 ,p{ .�i f �, • i 1 .+ F• ! ° 'a`", a £ ,.rte — For the township: On behalf of the township,I acknowledge that the organization is applying to conduct lawful gambling Print name of township activity within the township limits. A township has no statutory authority to approve or deny an Signature of township official receiving application application(Minn.Stat. sec.349.213,subd.2). / / Title Date For the county:On behalf of the county,I hereby acknowledge this application for lawful gambling activity at Print name of county the premises located within the county's jurisdiction,and that a resolution specifically approving or denying the application will be forwarded to the applying organization. Signature of county personnel receiving application / / Title Date The information requested on this form(and Your name and address will be public Board whose work assignment requires any attachments)will be used by the information when received by the Board. that they have access to the information; Gambling Control Board(Board)to All the other information that you provide the Minnesota Department of Public determine your qualifications to be involved will be private data about you until the Safety;the Minnesota Attorney General; in lawful gambling activities in Minnesota, Board issues your license. When the Board the Minnesota Commissioners of and to assist the Board in conducting a issues your license,all of the information Administration,Finance,and Revenue;the background investigation of you. You have that you have provided to the Board in the Minnesota Legislative Auditor, national the right to refuse to supply the information process of applying for your license will and international gambling regulatory requested;however,if you refuse to supply become public. If the Board does not issue agencies;anyone pursuant to court order; this information,the Board may not be able you a license,all the information you have other individuals and agencies that are to determine your qualifications and,as a provided in the process of applying for a specifically authorized by state or federal consequence,may refuse to issue you a license remains private,with the exception law to have access to the information; license. If you supply the information of your name and address which will remain individuals and agencies for which law or requested,the Board will be able to process public. legal order authorizes a new use or sharing your application. Private data about you are available only to the following: Board members,staff of the