01-11-2006 Council Agenda - Laserfiche WebLink

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Gambling Manager Requirements: I 1. An annual gambling manager license fee of $100 is required. ^gambling Manager Authorization GM- 04219 -003 Current License Term 5/1/2004 to 3/31/2006 Dorothy Dee Norgard 208 Nature Way, Little Canada, MN 55117 (651)490 -9299 IJ Bond: Western Surety Company 69670188 Last Education: 11/19/200 do,Zl.2c0,7't : U/17 - u/, 9 /Z045 Rp& Check this box if the person listed above will not be renewing as gambling manager. Enclose a separate LG212 application for the new applicant. Effective date will run concurrent with the organization's license. esree eo vQ J 4) Note: A new person may not assume or act as gambling manager until licensed by the Gambling Control Board. 1 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. 1.2. I am not involved directly or indirectly as a bingo hall wner, manufacturer, or distributor. Board Use Only 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 r ad,this application an declare th tall ' formation submit-kd is :rue, accrate nd comple Signature, in in , of gambli !g nanag appliF it Date: v' / / 0 17/ 0 (� 3