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Acknowledgment <br />Cambiteg Sit AnlbarlntlM <br />I hereby cofucm tfiai local lt«» enrorccfnent <br />ofTWcrt. Um boMd or agenii of the board, or <br />e»t flwowilMiooer of re»tmie or <br />piMic or tgenct of die <br />commit^ <br />Pigc2of2 <br />t, may coaer ihe preniaca to <br />enforce toe law <br />Baak Rccor^i bfbrmatioa <br />Theboarditftiihofucdto mspect the bank <br />recofdi of toe gambting account whenever <br />Moeuary to Aitfin reHuirtments ofcuireni <br />ftmbUngruletmdlaw <br />OrgMiaUM Uccast AirtlioHatleii <br />I hereby autooHar toe Gambling Control <br />Board lo modiiy the claa of organuatiofi <br />NoriiK to be oondstent with the claa of <br />peirnii being appl«d for <br />Oath ^ <br />Ideclaretoa; <br />I. lh»*«i«»<Hh»in,lic*ioo.nd.i| <br />biforraaioo tubmised lo toe board it »ue. <br />accuraa. and complete; 7. <br />2 ell other required tnibrmadon hat been <br />Adlyditcloted. <br />3 lamdachiefexccutiveoflkerofthe <br />organiabon. <br />any changca in application inibematoa <br />wUI be tubmeied to toe board aid local <br />unit of government within tea days of <br />toe change; and <br />I undemand toa failure to pioeldt <br />required infoemation or providmg Ikbcor <br />otitkadiag ln‘^ . mayratthlnihe <br />denial or icvocaion of the licciac <br />4 lattumefWI ietpontibiliiy forihefaeand <br />la w All operaoc n of all activ diet to be <br />oonducted. <br />3 l'*illfamilian«mytdfwitolhelawiof <br />Minnetou governing law Ail gambling and <br />of toe board and agree, iriiocntcd. to <br />abide b> those laws and rukt. includeig <br />amendments to them. <br />Signature of the chief eiecuiive <br />ofTiccr (Designee may not sign) <br />Date <br />Qp->/o| <br />Onbch^rQfliMciO.lhaTb) wkno»kdf«ihi$i(iplK«ioil C',-L<j air-OcC>^0 <br />l^lj»ftil|jirtlui*»ci>*it>Mih«premis«locjie<l within Pnmii«3o7ei»~-----------------------------------------------— <br />toe a t> s j irudicuin. and that a re toluoon Specific ally , ^ » <br />approving or denying the application will be forwarded to <br />of city personnel receiving application <br />fv C.l-er'ic 9 lily, oj——L-f—L—x ___t. ^ ________y_/ y <br />—----------------------------------------------------------------------------------- > D,/ — <br />. I « I . . .. ^ ,u _______l'’ . ♦ <br />tat Iht ImmhlB. On bdnlfof ih> io>.n.hip. I «ckno»lcJ,« ~ <br />thJi ihc ortiiiijuon U appK tn$ k> conduct law Ail (amblinf =—------------------------------------------______________ <br />activity within toe low luhip I uni tv Pnm name of township <br />^•■u«ofa.wn.hip,»,cial ir«w.n,.pp.Kaoon <br />J____/ <br />LOLIbC aum> On behalf of the county, thereby _____ <br />acknowledge this application for lawful gambling activuv « Phiil nxneofcounty <br />the premises located within toe county ’s/uriidiction. and* <br />that a resolution spedAmOy approving or denying the <br />applicaiion will be forwarded to the arr»>*ng organiraiion Signature ofoountv personnel recerving plication <br />The mformalion requested on this form (and <br />Oily anachments) will be used by Ihc <br />CamWing Conool Board (Board) lo <br />df afmme your quahAcationa to be involved <br />m lawful gambling aaivioes in Mmnesou. <br />and to asm the Board in conduceng a <br />bakigroundinvesiigaiicnof you You have <br />toe nght to rr Aise to supply toe informal ton <br />requested, however, if you rcAase to supphr <br />toll aifoemaooA. toe Board may not be able <br />to determine your qualificaDons and» as a <br />consquenoe. miy rcAtsc to issue you a <br />keen* Ifyou supply toe infoemaikM <br />requested, toe Board wiO be able to process <br />your applicmnn. <br />Your name and address w U] be public <br />mformalion when recew ed by Ihe Board <br />All the other infomution that you provide <br />will be private data about you imttl the <br />Board issues your iKcnst When toe Board <br />issues your license, all of toe mformatton <br />toal you have provided to Ihc Bo*d to the <br />pwess of applying for your license wOI <br />become public IftiscBtwddoetnocisuc <br />>ou a license, ail toe mformaiton you have <br />provided in toe peoces of applying foe a <br />li«n* remsRs pnvate. wito toe cxccpetoo <br />of your itamc ssd addres which win mnton <br />public <br />Board whose work assignmeni requets <br />lhai they have access to the infoetmoon. <br />toe Mmnesou Depanmcniof Pubkc <br />Safety; the Minncaou Aaomey General <br />toe MtooesouCommisstoneflof <br />Admimstration.rinsicc.a«dlUvcnue toe <br />Miimesou Legtslaiive Audmse. n^onal <br />«d totemsional gambling regulatory <br />tigcndcs. anyone pursuant to court order, <br />otoer individuate and agcndcs toat are <br />tproiflcaHy autooriaed by stsc or fodcral <br />law to have access to toe tofoc <br />todhitomte and agendcs for which law or <br />Frivaiedtoai I you are avadaWc only to