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Gambling Manager License Renewal Application (Continued) Page 2 of 2 Affidavit and Consent Statement of Gambling Manager Applicant I, (print name) Mary Ann Mildred Auge O'Kane Qualifications and Restrictions. 1. I have never been convicted of a felony, or crime involving gambling. 2. I have never commited 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 now, connected with nor 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. , under oath state that: 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. 10. I am not acting as a gambling manager for more than one organization and am not an assistant gambling manager for another organization. 11. I am not a lessor, a member of the immediate family, or an employee of a lessor of a premises where the organiza- tion 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 the organization. 14. I am not the treasurer of the organiza- tion. This is the person who accounts for the revenues of the organizational monies. Seminar. I understand a gambling manager must attend the two -day gambling manager seminar and pass the gambling manager examination administered by the Gambling Control Board. In the case of an emergency gambling manager change, training and passing the examination must be completed within 90 days of being issued a license. Further, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of the attached gambling manager license application, or acts or omissions arising from such application, may be commenced against me or my organization and 1 will accept the service of process in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary o f State of any summons, process, or pleading authorized by the laws of Minnesota Failure to provide the required information or providing false or misleading information may result in the denial or revocation of the license. FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the application for a gambling manager license from the Gambling Control Board. I have read this application and declare that all the information submitted is true, accurate and complete. Notary Public Information. Notary Public Seal must be current and correct; seal may not be altered. Subscribed and swum to before me this a day of `� a- ,u,1,anCCQ 0 ..cc./ Notari d Signature of Applicant Notary Public Date: ,r-r— 6c. The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your qualifications to be involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of you. You have the right to refuse to supply the information requested; however, if you refuse to supply this information, the Board may not be able to determine your qualifications and, as a consequence, may refuse to issue you a license. If you supply the information requested, the Board will be able to process your application. Your name and address will be public information when received by the Board. A the other information that you provide will be private data about you until the Board issues your license. When the Board issues your license, all of the information that you have provided to the Board in the process of applying for your license will become public. If the Board does not issue you a license, all the information you have provided in the process of applying for a license remains private, with the exception of your name and address which will remain public. Private data about you are available only to the following: Board members, staff of the Page 9 U KATHLEEN A. GLANZER NOTARY PI$LIC - MINNESOTA MY COMMISSION _ CalKtb JAN. -3 r • t ::.rd „ ,. -- 'es Mat they have access to the information; the Minnesota Department of Public Satery; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies that are specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent.