05-25-1999 Council Agenda - Laserfiche WebLink

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Gambling Manager Renewal Application (continued) Affidavit and Consent Statement: I,(printname) Robert Gordon Johnson 1. been convicted of a felony or crime involving gambling; 2. 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. been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gambling; 4. been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii) making terroristic threats; LG212GMR 09/96 Page 2 of 2 ,under oath state that I have never: 5. been, or am now, connected with nor engaged in an illegal business; 6. had a sales and use tax permit revoked by the commissioner of revenue within the past two years; 7. after demand, failed to file, tax returns required by the commissioner of revenue. I do not owe $500 or more in delinquent taxes as defined in section 270.72. In addition, 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 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. 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. 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 a gambling manager license from the Gambling Control Board. SIGNATURE OF GAMBLING MANAGER APPLICANT yy Notarized Signature ofpplicauit :.° a Lil'IDA L. FAHEY % � ? •;'` " K r NO TA 19.'11,1('- llP.NFSO'id RAMSEY COUNTY -' Date 05/18/99 Notary Public Information. Notary Public Seal must be current and correct; seal may not be altered. Subscribed and sworn to before me this 18th day of May ,19 99 . Notary Public s This publication will be made available in alternative format (i.e. large print, Braille) upon request. If you use a TTY, you can call us using the Minnesota Relay Service at (612) 297 -5353 or 1 -800- 627 -3529 and ask them to place a call to (612) 639 -4000. The information requested on this form will be used by the Gambling Control Board (Board) to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. All of the information that you supply on this form will become public information when received by the Board. You are required to provide your social security number on this form. Your social security number will be used to determine your compliance with the tax laws of Minnesota. Authorization for requiring your social security number is found at 42 U.S.C. 405(c)(i). The information requested on this form (including any attachments) will be used by the 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 required, the Board will be able to process your application. Your name and address will be public information when received by the Board. All the other information about you that you provide will be private data until the Board issues your license. When the Board issues your license, all of the information you have provided to the Board in the process of applying for your license will become public except for your social security number, which remains private. 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 is available only to the following: Board the Minnesota Department of Public Safety; the Minnesota Attor Page 152 national and intemational gambling regulatory agencies; anyone or federal law to have access to such information; individuals and agencies ror .,,......,. notice is given; you; and anyone with your written consent. k assignment requires that they have access to the information; hers of Administration, Finance and Revenue; the Legislative Auditor; 1s and agencies that may be specifically authorized by state authorizes a new use or sharing of the information after this