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Bingo Hall Personnel Information - LG315
<br />License number: 814046 Name of person:
<br />Mark Allen Hotzler
<br />Oath and Consent Statement
<br />I have never been convicted of a
<br />fdony.
<br />2. I have never been convicted of a crime
<br />involving gambling.
<br />3. I have never been convicted of assault,
<br />a criminal violation involving the use of
<br />a firearm, or making terroristic threats.
<br />4. I am not currently or have never been
<br />engaged in or connected with an illegal
<br />business.
<br />5. I do not owe $500 or more in
<br />delinquent taxes to the state of
<br />Minnesota.
<br />6. I have not had a sales and use tax
<br />permit revoked by the commissioner of
<br />revenue within the last two years.
<br />7. I have filed, after demand, tax
<br />returns required by the commissioner of
<br />revenue.
<br />8. I am not a licensed distributor or
<br />affiliate of a distributor under Minn.
<br />Stat. sec. 349.161.
<br />9. I am not a licensed manufacturer or
<br />affiliate of a manufacturer under Minn.
<br />Stat. sec. 349.163.
<br />10. I will not be an officer, director, paid
<br />employee, or volunteer of a licensed,
<br />exempt, or excluded organization in its
<br />conduct of lawful gambling, or
<br />represent a licensed, exempt, or
<br />excluded organization in the purchase
<br />of or influence the purchase of lawful
<br />gambling equipment
<br />I am not a wholesale distributor or an
<br />affiliate or an employee of a wholesale
<br />distributor of alcoholic beverages.
<br />12. I will not provide any staff to conduct or
<br />assist in the conduct of bingo or any
<br />other form of lawful gambling on the
<br />premises.
<br />13. I will not acquire gambling equipment
<br />or provide inventory control for any
<br />organization that conducts lawful
<br />gambling on the premises.
<br />14. I will not prepare or assist in the
<br />preparation of any reports required by
<br />Minn. Rules, part 7861.0120, subp. 3,
<br />for an organization conducting lawful
<br />gambling on the premises.
<br />15. I will not provide accounting services to
<br />any organization conducting lawful
<br />gambling on the premises.
<br />16. I will not solicit, suggest, encourage, or
<br />make any expenditures of an
<br />organization's gross receipts from lawful
<br />gambling.
<br />17. I will not charge any fee to a person
<br />without which the person could not play
<br />bingo or participate in another form of
<br />lawful gambling on the premises.
<br />18. I will not provide assistance or
<br />participate in the conduct of lawful
<br />gambling on the premises.
<br />1. 19.
<br />11.
<br />20.
<br />21.
<br />22.
<br />23.
<br />I will not permit more than 21 bingo
<br />occasions to be conducted on the
<br />premises in any week.
<br />I will not recruit a person to become a
<br />gambling manager or assistant gambling
<br />manager or identify to an organization a
<br />person as a candidate to become a
<br />gambling manager or assistant gambling
<br />manager.
<br />I will not be involved in the procurement
<br />of, or influencing the procurement of,
<br />lawful gambling equipment for an
<br />organization which conducts lawful
<br />gambling on the licensee's premises.
<br />I will not provide or permit an affiliate or
<br />person acting on behalf of the bingo hall
<br />licensee to provide any compensation,
<br />gift, gratuity, premium, contribution, or
<br />thing of value to a Gambling Control
<br />Board employee or member of the
<br />Gambling Control Board.
<br />I will not directiy or indirectly give gifts,
<br />trips, prizes, loans of money, premiums,
<br />or other gratuities to gambling
<br />organizations, or their employees, other
<br />than nominal gifts not to exceed a value
<br />of $25 per organization in a calendar year.
<br />In addition, I understand, agree, and hereby
<br />irrevocably consent that suits and actions
<br />relating to the subject matter of the bingo hall
<br />license application, or acts or omissions
<br />arising from such application, may be
<br />commenced against me in any court of
<br />competent jurisdiction in Minnesota by service
<br />on the Minnesota Secretary of State of any
<br />summons, process, or pleading authorized by
<br />the laws of Minnesota.
<br />By signature of this document, the undersigned
<br />authorizes the Department of Public Safety to
<br />conduct a background investigation pursuant to
<br />Minnesota Rules, part 7862.0010, subpart 10a.
<br />By signature of this document, the undersigned
<br />attests that information provided in this
<br />application is true and correct. Failure to
<br />provide required information, or providing false
<br />or misleading information, may result in the
<br />denial or relocation of the license.
<br />Changes in application information will be
<br />submitted within ten days.
<br />FURTHER AFFIANT SAYE'iH NOT, except that
<br />this Oath and Consent Statement is submitted
<br />in support of the application for a bingo hall
<br />license from the Gambling Control Board.
<br />as4?ai,
<br />(Signature of bingo hall pers
<br />County of __2H_l Sri
<br />before me this
<br />Notary Public:
<br />My commission expires: m I / 3/ / 62.r
<br />5
<br />el applicant)
<br />/C /c.j7 / v
<br />Date signed
<br />Subscribed and sworn to
<br />day of 0 erR746111- 20e1 _
<br />PAUL W. NOIAN
<br />Notary seal:? \� My CommR s oU Expires INan. 31, 2005
<br />The information requested on this form (and any attxhments) will be used by the Garbling Control Board
<br />(Board) to determine your qualifications to be invdved in lawful garbling activities in Minnesota, and to assist
<br />the Board in conducting a background investigation of you. You have a right to refuse to supply the
<br />information requested; however, if you refuse to supply this information, the Board may not be able to
<br />determine your qualifications and, as a consequence, may refuse to register you. If you supply the information
<br />requested, the Board will be able to register you. You are required to provide your social security number on
<br />this form. Your nodal security number will be used to determine your compliance with the tar laws of
<br />Minnesota. Authorization for requiring your social security number is found at 42 U.S.C. 905 (cXi). Your name
<br />and address will be public information when received by the Board. All the other information that you provide
<br />will be private data about you until the Board approvesyour registration. When the Board approves your
<br />registration, all of the information that you have provided to the Board in the process d registering will become
<br />public except for your social security number, which remains private. If the Board does not approve your
<br />registration, all the information you have provided in the process of registering remains private, with the
<br />exception of your name and address, which will remain public. Private data about you are available only to the
<br />following: Board members, staf of the Board whose work assignment require that they have access to the
<br />Information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota
<br />Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor; national and
<br />international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that
<br />are spedfically authorized by state or federal law to have access to the information; individuals and agencies for
<br />which law or legal ceder authorizes a new use or sharing of information after this notice was giver aid anyone
<br />with your ---
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