Resolution 98-04 - Laserfiche WebLink

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Acknowledgment Page 2 of 2 Gambling Site Authorization Oath 6. any changes in application I hereby consent that local law enforcement I declare that: information officers,the board or agents of the board,or 1. I have read this application and all will be submitted to the board and the commissioner of revenue or information submitted to the board is true, local public safety or agents of the commissioners, accurate, and complete; unit of government within ten days of may enter the premises to enforce the law. 2. all other required information has been Bank Records Information fully disclosed; the Change;and The board is authorized to inspect the bank 3. I am the chief executive officer of the 7. I understand that failure to provide records of the gambling account whenever organization; required information or providing necessary to fulfill requirements of current 4. I assume full responsibility for the fair and false or gambling rules and law. lawful operation of all activities to be misleading information may result in Organization License Authorization conducted; the I hereby authorize the Gambling Control 5. I will familiarize myself with the laws of t na re f t he t�v Board to modify e class of organization y of rer(De donee m �not sign�]se. �' g Minnesota governing lawful gambling and oilIItcer estgnee may not sign)) license to be consistent with the class of rules of the board and agree, if licensed,to permit being applied for. abide by those laws and rules, including amendments to them; Date Local Unit of Government Acknowledgment and Approval =Ifthegambhng,premises is within-6W Iin - tfie city must sign this application an a ` vtutioi f On behalf of the city,I hereby acknowledge this C i t y of P P r1 n o t Lakes application for lawful gambling activity at the premises located Print name of city within \., � / .. - _� �� the city's jurisdiction,and that a resolution specifically Signature of city personnel receiving application 01/ 24 / 00 If the gambling premises is located in a township bath the county and township must sign thi ,application The county roust provide a resolutiot d. , ,��,an.,.a.a� exm,.b:..� ��.,�....� .�...�_> ...ate„.,.....a��a�.. s,A�.i �� -.�s�_,.�s�w..,;.�,..�,,.�� m<�a � -= W?. ��.. w�3,. For the township:On behalf of the township,I acknowledge that the organization is applying to conduct lawful Print name of township ikattlWiilltip has no statutory authority to approve or deny an application(Minn. Stat. sec.349.213,subd.2). Signature of township official receiving application / / 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 Signature of county personnel receiving application application will he forwarded to the applying / The information requested on this form(and Your name and address will be public Board whose work assignment requires that any attachments)will be used by the Gambling information when received by the Board. All they have access to the information;the Control Board(Board)to determine your the other information that you provide will be Minnesota Department of Public Safety;the qualifications to be involved in lawful gambling private data about you until the Board issues Minnesota Attorney General;the Minnesota activities in Minnesota,and to assist the Board your license. When the Board issues your Commissioners of Administration,Finance, in conducting a background investigation of license,all of the information that you have and Revenue;the Minnesota Legislative you. You have the right to refuse to supply the provided to the Board in the process of Auditor,national and international gambling information requested;however, if you refuse applying for your license will become public. regulatory agencies;anyone pursuant to court to supply this information,the Board may not If the Board does not issue you a license,all the order,other individuals and agencies that are be able to determine your qualifications and,as information you have provided in the process specifically authorized by state or federal law a consequence,may refuse to issue you a of applying for a license remains private,with to have access to the information;individuals license. If you supply the information ' the exception of your name and address which and agencies for which law or legal order requested,the Board will be able to process will remain public. authorizes a new use or sharing of your application. information after this notice was given;and Private data about you are available only to the anyone with your written consent. following: Board members,staff of the