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e ° LG214 Premises Permit Application 6/15 Page 2 of 2 ACKNOWLEDGMENT BY LOCAL UNIT OF GOVERNMENT: APPROVAL BY RESOLUTION CITY APPROVAL COUNTY APPROVAL for a gambling premises for a gambling premises located within city limits located in a township City Name: County Name: Date Approved by City Council: Date Approved by County Board: Resolution Number: Resolution Number: (If none,attach meeting minutes.) (If none,attach meeting minutes.) Signature of City Personnel: Signature of County Personnel: Title: Date Signed: Title: Date Signed: TOWNSHIP NAME: Complete below only if required by the county. Local unit of government On behalf of the township,I acknowledge that the organization is must sign. applying to conduct gambling activity within the township limits. (A township has no statutory authority to approve or deny an application, per Minnesota Statutes 349.213,Subd.2.) Print Township Name: Signature of Township Officer: Title: Date Signed: ACKNOWLEDGMENT AND OATH 1. I hereby consent that local law enforcement officers, 6. I assume full responsibility for the fair and lawful operation of the Board or its agents,and the commissioners of all activities to be conducted. revenue or public safety and their agents may enter and inspect the premises. 7. I will familiarize myself with the laws of Minnesota governing 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 account whenever necessary to fulfill requirements of 8. Any changes in application information will be submitted to the current gambling rules and law. Board no later than ten days after the change has taken effect. 3. I have read this application and all information submitted to the Board is true,accurate,and complete. 9. I understand that failure to provide required information or providing false or misleading information may result in the 4. All 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-refundable regardless of license approval/denial. ��,.►� 4, 4 /6 - ,,,/o4 3 Signature o Chief Executive Officer(designee may not sign) Date Data privacy notice:The information requested on this information when received by the Board. Minnesota's Department of 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 determine your private data about your organization until Administration,Minnesota Management& organizations qualifications 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 information national and international gambling the right to refuse to supply the information;however, provided will become public. If the Board regulatory agencies;anyone pursuant to if your organization refuses to supply this information, does not issue a permit,all information court order;other individuals and agencies the Board may not be able to determine your provided remains private,with the specifically authorized by state or federal law organization's qualifications and,as a consequence, exception of your organization's name and to have access to the information;individuals may refuse to issue a permit.If your organization address which will remain public. Private and agencies for which law or legal order supplies the information requested,the Board will be data about your organization are available authorizes a new use or sharing of able to process your organization's application. Your to: Board members,Board staff whose information after this notice was given;and organizations name and address will be public work requires access to the Information; anyone with your written consent. This form will be made available In alternative format,I.e.large print,braille,upon request. An equal opportunity employer