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nnualfGambUrfig t an"age <br />icense <to <br />GM License #: 01485 -001 <br />Current License: 4/1/2002 to 3/31/2004 <br />Gambling Manager: Elizabeth Louise Matson <br />Home Address: 2774 Dellwood Ave, Roseville, MN 55113 <br />Phone: (651)633 -0156 <br />Date of Birth: 6/29/1940 <br />Social Security #: 469 -44 -9487 <br />Bonding Insurance Co: Western Surety <br />Bond #: 58247021 <br />Most Recent Education: 11/21/2002 <br />Board Use Only <br />We will not be renewing this person as gambling manager. Enclosed is a separate LG212 application I <br />Note: A new gambling manager may not assume duties until licensed by the Gambling Control Board. <br />:�;.au t C <br />. I have never been convicted of a felony or a crime <br />involving gambling. <br />2. I have never committed a violation of law or Board <br />rule that resulted in the revocation of a license issued <br />by the Board within five years before the date of the <br />license application. <br />3. I have never been convicted of a criminal violation <br />involving fraud, theft, tax evasion, misrepresentation, <br />or gambling. <br />4. I have never been convicted of (i) assault, (ii) a <br />criminal violation involving the use of a firearm, or (iii) <br />making terroristic threats. <br />5. I have never been, or am I now, connected with or <br />engaged in an illegal business. <br />6. I have never had a sales and use tax permit <br />revoked by the commissioner of revenue within the <br />past two years. <br />7. I have never, after demand, failed to file tax returns <br />8. I do not owe $500 or more in delinquent taxes as <br />defined in section 270.72. <br />9. I have been an active member of the organization. <br />10. I am not a gambling manager or an assistant <br />gambling manager for another organization. <br />11. I am not a lessor, a member of the immediate <br />family, or an employee of a lessor of a premises where <br />this organization has a permit issued from the Board <br />to conduct lawful gambling. <br />12. I am not involved directly or indirectly as a bingo <br />hall owner, manufacturer, or distributor. <br />13. I am not the chief executive officer of this <br />organization. <br />14. I am not the treasurer of this organization. <br />Background Check. By signature of this document, the <br />undersigned authorizes the Departments of Public Safety and <br />Revenue to conduct a criminal and tax background check or <br />review and to share the results with the Gambling Control <br />Board. Further, I understand, agree, and hereby irrevocably <br />consent that suits and actions relating to the subject matter <br />of this gambling manager license application, or acts or <br />omissions arising from such application, may be commenced <br />against me or my organization and I will accept the service of <br />process in any court of competent jurisdiction in Minnesota by <br />service on the Minnesota Secretary of State of any summons, <br />process, or pleading authorized by the laws of Minnesota. <br />Failure to provide required information or providing false or <br />misleading information may result in the denial or revocation <br />of the license: <br />I have read this application and declare that all information <br />submitted is true, accurate, and complete. <br />Notayiied signature o gambling manager applicant <br />Date: « 02 9 -d <br />Notary Public Seal must be current and correct; seal may <br />not be altered Subscribed and sworn to before me this <br />day of <br />Notary public <br />D &ten - z e , 2_003 , <br />8 <br />x iff7.';'\ t,. <br />IYE P ELLEN SCHMIDT <br />, <br />NOTARY <br />ISSIQNXPIRES S07p <br />;, ,✓.'� MYCOMMISSION EXPIRES 1.342005 <br />