CCP 02-24-2009 - Laserfiche WebLink

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License Number: 32235 License Expiration: 3/31/2009 Chief Executive Olficees Acknowledgement -and Oath I declare that: I have read this appik3tion and all information submitted to the Board. AN information is true, accurate and complete. All other required information has been fully disclosed. I am the chief wcutive ofd of the organization. I assume full responsibility for the fair and lawful operation of all gambling activities to be conducted. I will familiarize myself With the laws of Minnesota governing lawful gambling and rules of the Board. and agree, If licensed, to abide by those. laws and rules, inducing amendments to them. . I ter* that the gambling manager Is bonded and licensed as I have read this application and declare that all required per Minnesota Statutes. information submitted is true, accurate, and I understand that failure to provide required information or providing complete. r false or misleading information may result in denial or revocatfon,of the license. 6�i .� 3G•� -----� -- A termination plan will be submitted to the Board within 30 days of Signature, In Ink,.of thief accutive officer termination of our gambling operation. Deft: OG ...------ ... .---.... ............ ... ... .., .Mail cornolete renewal application (all pages), and one check made payable to the State of Minnesota for all renewal fees4by: 1/30/2009 to: Gambling Control Board 1711 W Co Rd B #300 S - ---•- .................... Roseville; ..._.... .................. AW-1censing Contact: Kim Larsson Emall: klm.larsson@gc.b.state-mn.us Phone: (651)634.4072 Fax #: (651) 639-4032 The hf+amation requested on this from (and any attachnerrts) will be used by the Gambling Control Baud (Board) to determine your qualrcaWns iQ be involved In IaW UI garrmng activities in Minnesota, and to assist the Board In ung a badground WNeSU c n of You. You have the right to refile to supply the Information requested, howem, Iryou muse to supply this ktomratlon, the Board may not be able to determine Your quallflodlons am, as a am erre, may refuse to issue you a license. If you supply the irfbrmation requeod, the Board will be able to F=m Your appy Your name and address will be public Information when.reoelved by the Board. AN the other lydorrnatloq that you provide will be private daita ab" you until the Board ham your Noertse. When the Board issues Your license, all of the information that you have provided to the Board in the prods of applying for your license will begonia public except for Yat Social SeaM rawaff, which Mains private. If the Board does not Issue you a lloense, all kftmoon You have provided in the process of applying for a remains private^, with the eraeptiOn of Your name and address which willrernalrr PuW- Private data abaa you aro VvaYable ordy to the fallowing: Board mernbers, Board staff'whose work assignment. requires that they have access. to the kdornt Mon; the minnesom Departriml of Ptrbk Safoty: the Minnesota Attorney General: the Minnesota Co nrrAWOnm of AdrWr>isbation, Finance, and pz4er , the Minnesota terve Auditor, national and International gambling regulatory -agger%: arW*PurAk1nttD0oWt ander; other 6rolviduais and agencies that are specillc* arthortted by state or federal law to have access to the InibnTedon: kKlvkkgds and agendas foau r whkh law or legal order thorizes a new use ar sharing d kftOlWm after U* Notlae was Win,• and anyone wBh yea written consent OtWOA 0- PAWAVe APP: PAPO