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LG213 Minnesota Lawful Gambling <br /> (Rev. 6/12/92) Gambling Manager Affidavit <br /> (Attach to the Gambling Manager Application. Form LG212) <br /> STATE OF n/ AFFIDAVIT OF QUALIFICATION <br /> s.s. FOR GAMBLING MANAGER LICENSE <br /> COUNTY OF 1,l/ S -Y AND CONSENT STATEMENT <br /> J (Pursuant to Minnesota Statute 349.16 Subd. 2(e) <br /> and Minnesota Rule 7861.0030,Subp. 128(3)) <br /> ras under oath state that: <br /> (type /print name) <br /> 1. 1 have never been convicted of a felony. <br /> 2. I have not, within five years, committed a violation of law or board rule that resulted in the <br /> revocation of a license issued by the Lawful Gambling Control Board. <br /> 3. I have never been convicted of a criminal violation involving fraud, theft, tax evasion, <br /> misrepresentation, or gambling. <br /> 4. I have never been convicted of assault, a criminal violation involving the use of a firearm, <br /> or making terroristic threats. <br /> 5. I am not an assistant gambling manager for any other organization. <br /> 6. I am not a gambling manager for any other organization. <br /> In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject <br /> matter of the attached gambling manager license, or acts or omissions arising from such application, may <br /> be commenced against my organization and 1 will accept the service of process for my organization in any <br /> court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, <br /> process or pleading authorized by the laws of Minnesota. <br /> By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a <br /> criminal background check or review and to share the results with the Lawful Gambling Control Board. <br /> Failure to provide required information or providing false or misleading information may result in the denial <br /> or revocation of the license. <br /> Subscribed and sworn to before me this .4 Z4g <br /> (Signs re of applicant gambling manager) <br /> ■9 day of 19 1 5cv /t° AreA Yv <br /> (Name of organization) tic /C <br /> County Air /q-03/9 BONNIE J. SCOTT License number <br /> Nota Public r ANOKA COUNTY <br /> ry My commission expires 6 -10-98 <br /> My commission expires <br />