05-25-1999 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling Organization Officers Affidavit - LG200B State of MINNESOTA ss. County of RAMSEY 1, 1. James W. Gustafson I have not been convicted of a felony or gross misdemeanor within the five years before the issuance or renewal of the license. 2. I have never been convicted of a crime involving gambling. 3. I have never had a license issued by the board or director permanently revoked for violation of law or board rule. In addition, I understand, agree, and hereby irrevocably consent that suits and actions relating to the subject matter of the organization license application, or acts or omissions arising from such application, may be commenced against my organization and I will accept the service of process for my organization 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. Notary Public Information Notary Public Seal must be current and correct. The seal may not be altered. Subscribed and sworn to before me this 1 8 th day of May 19 99 . (No ublic Signature) LINDA L. FAHEY Mail this form to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113 Affidavit of Qualification of Officers for an Organization License and Consent Statement (pursuant to Minnesota statutes) under oath state that: By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a criminal background check or review and to share the results with the Gambling Control Board. Failure to provide 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 an organization license from the Gambling Control Board. Applicant Information Check the box indicating your position: Chief Executive Officer t 1 Treasurer X � Effective Date of Officer Change 01 / 15 / 9 3 Home Address 2569 Ruth Street City Little Canada State/Zip MN 55117 Phone ( 651 ) 484 -7973 Date of Birth 11 / 20 /56 Name of OrganizationL i t t le Canada Vo1.Fin Base License Number A -00864 Questions on this form should be directed to the Licensing Section of the Gambling Control Board at 651 - 639 -4000. This publication will be made available in alternative format (i.e. large print, Braille) upon request. Hearing impaired individuals using a TTY may call the Minnesota Relay Service at 1 -800- 627 -3529 and ask to place a call to 651 - 639 -4000. The information requested on this form will becombe public information when received by the Board, and will be used to determine your compliance with Minnseota statutes and rules governing lawful gambling activities. Page 138 (9/98) Dept