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LG214 Premises Permit Application ei�s Page 2 of 2 ACKN�WLEDGMENT BY LOCAL UNIT OF 60VERNMENT: APPROVAL BY RESOLUTIOW CITY APPROVAL COUNTY APPROYAL � for a gambling premises for a gambling premises located within city limits located in a township City Name: Pequot Lakes County Name: Date Approved by City CounciL• G-G-/7 Date Approved by County Board: Resolution Number: �7' 2 ( Resolution Number: (If none,attach meeting minutes.) (If none,attach meeting minutes.) Signature of City Personnel: Signature of County Personnel: /1��.�, �a�2�'�c/� Title: G,-�� A c�m�n r s��c��o� Date Signed: G-7-l 7 Title: Date Signed: TOWNSHIP NAME: Complete below only if required by the courrty. Local unit of government On behalf of the township,I acknowledge that the organization is must sign. applying to conduct gambling act�vity within the township limits. (A township has no statutory authority to approve or deny an application, per Minnesota Statutes 349.213,Su(�tl. 2.) Print Township Name: Signature of Township OfFcer: Title: Date Signed: ACKNOWLEDGMENT AND�ATH i. I hereby consent that locai law enforcement officers, 6. I assume full responsibility for the fair and lawful operation of the Board or its agents,and t#�e commissloners of all activities to be conducted. revenue or public safety and their agents may enter � I will familiarize myself with the laws of Minnesota goveming and inspect the premises. lawful gambling and rules of the Board and agree,if licensed, 2. The Board and its agents,and the commissioners of to abide by those laws and rules, including amendments to revenue and public safety and their agents,are them. authorized to inspect the bank records of the gambling g Any changes in application information will be submitted to the account whenever necessary to fulfill requirements of goard no later than ten days after the change has taken current gambling rules and law. e�� 3. I have read this application and all information g, I understand that failure to provide required information or submitted to the Board is true,accurate,and complete. providing false or misleading information may result in the 4. Ail required information has been fully disclosed. denial or revocation of the license. 5. I am the chief executive officer of the organization. 10. I understand the fee is non-refundab{e regardiess of license approval/denial. 5 �8' Zol� Sign of Chief F.�cecutive Officer(designee may not sign) Date Data privacy notice:The information requested on this information when received by the Board. Minnesota's Department af 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 determtne your private data about your organizadon until Administration,Mfnnesota Management& organization's qualificatlons to be involved in lawful the Board issues the permit. When the Budget,and Revenue; Legislative Auditor, gambling activities in Minnesota.Your organization has Board issues the permit,all Informatlon nadonal and intemational gambling [he right to refuse to supply the informatlon; however, provided will become public. If the Board regulatory agencies;anyone pursuant to ff your organization refuses to suppiy this information, does not issue a permit,all informatlon court order;other Individuals and agencies the eoard may not be able to determine your provided remains private,with the speciflcally autho�ized by state or federel law organization's qual�cadons and,as a consequence, exception of your organizatian's name and to have access to the Information; tndividuals may refuse to issue a permit.If your organization address which w(II remafn public. Private and agencies for which law or legal order supplies the InformaUon requested,the Board wfll be data about your organization are available authorizes a new use or sharing of able to process your organkatlon's application. Your to: Board members,Board staff whose informatlon after this notice was given;and organizatlon's name and address wili be public work requires access to the(nformatlon; anyone with your written consent. This form will be made avaflable in altemative format,(.e.large print,braille,upon request. M equal opportunity employer