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Ga bling Control Minnesota Lawful Gambling (LG200R) Lawful Gambling License Renewal Application Corrections should be made directly on this application Submit one check for all renewal fees, payable to State of Minnesota Organization requirements: Current license term: 4/1/2006 to 3/31/2008 1. An annual organization license fee of $350 is required. Renewing license term: 4/1/2008 to 3/31/2010 Authorization #: 1485 Organization: North Suburban Youth Foundation 1970 Oakcrest #118, Roseville, MN 55113 CEO: Richard R Matson 2774 Dellwood St, Roseville, MN 55113 Treasurer: Dale L Maristlien 5705 Dunlap Ave, Shoreview, MN 55126 (651)780 -9872 (612)638 -4600 County: Ramsey (612)889 -4463 Check this box If your organization qualifies for the waiver of the $350 organization license fee defined in MN Statute 349.16 600, 6j Annual Goal for Charitable Contributions a/o Gambling Manager Requirements: 1. An annual gambling manager license fee of $100 is required. Gambling Manager Authorization: GM- 01485 -001 Current License Term: 4/1/2006 to 3/31/2008 Renewing license term: 4/1/2008 to 3/31/2010 Elizabeth Louise Matson 2774 Dellwood Ave, Roseville, MN 55113 (651)633 -0156 Bond: # RPS 579134 Company: Old Republic Surety E] The individual listed is not renewing their license. We have enclosed a LG212 application for the new applicant. Note: The gambling manager duties may not be assumed by an individual until they are licensed by the Minnesota Gambling Control Board. Gambling Manager Affidavit and Consent Statement 1. I have never been convicted of a felony or a crime involving gambling. 2. I have never committed a violation of law or Board rule that resulted in the revocation of a license issued by the Board within five years before the date of the license application. 3. I have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. I have never been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii) making terroristic threats. 5. I have never been, or am I now, connected with or engaged in an illegal business. 6. I have never had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 7. I have never, after demand, failed to file tax returns required by the commissioner of revenue. 8. I do not owe $500 or more in delinquent taxes as defined in section 270.72. 9. I have been an active member of the organization for at least two years at the time of our organization's initial license application, or have been an active member for at least the most recent six months prior to the effective date of our organization's license renewal. 10. I am not a gambling manager or an assistant gambling manager for another organization. 11. I am not a lessor, a member of the lessor's immediate family or a person residing in the same household as the lessor, or an employee of a lessor of a premises where this organization has a permit issued from the Board to conduct lawful gambling. 12. I am not involved directly or indirectly as a bingo hall owner, manufacturer, or distributor. 13. I am not the chief executive officer of this organization. 14. I am not the treasurer of this organization. 15. I was not an officer of an organization at a time when an offense occurred which caused that organization's license to be revoked. Background Check. By signature of this document, the undersigned authorizes the Departments of Public Safety and Revenue to conduct a criminal and tax background check or review and to share the results with the Gambling Control Board. Further, I understand, agree, and hereby irrevocably consent that suits and actions relating to the subject matter of this gambling manager license application, or acts or omissions arising from such application, may be commenced against me or my organization and I will accept the service of process in any court of competent . jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pleading authorized by the laws of Minnesota. Failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. Changes in the information submitted in this application will be submitted in writing no later than 10 days after the change has taken effect. I have read this application and declare that all information submitted is true, accur.te, and c,. . plete_� • Sign re, in ink, of gambling manager applicant Date: / / % / 0