11-26-1997 Council Agenda - Laserfiche WebLink

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Minnesota Lawful Gambling Organization Officers Affidavit - LG200B y 4,/G % /> 6 i%/t/r 0 /7 1. 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. 1 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 % day of C {'� ��° 19 97 . (Notary PubS5lic,Signature). ,,,,,,,,, ,,,,,,,,,,nnn. 2 KATHLEEN A. GLANZER Y NOTARY PUBLIC-MINNESOTA Questions on isco.p m oL4d ErN �'t hey dc.eg�Ing Section of the GambliggS�y„ar`a at.('b°]`2 QQ(SvTuv publication will be made available in alternative format (i.e. Iarge 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 (612) 639 -4000. Pursuant to Minnesota Statutes, section 13.04, subdivision 2, you are hereby informed that the information requested on this form 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. ss. 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. (Ap can Signature) Applicant Information Check the box indicating your position: Chief Executive Officer, Treasurer 1 Effective Date of Officer Change / / Horne Address City State/Zip Phone ( ) Date of Birth / / Name of Organization Base License Number Upon receiving a lawful gambling license, all application data provided by you will become public data. Prior to receiving a license, the application information (with the exception of your name and address, which are public) is considered private data on individuals and will be available only to the following: Gambling Control Board members; staff of the Board whose work assignment requires that they have access to the information; the Minnesota Department of Public Safety; the Minnesota Attorney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota Legislative Auditor; national and international gambling regulatory agencies; parties to judicial proceedings pursuant to court order; other individuals or agencies that may be specifically authorized by state statute or federal law to have access to such information; and individuals and agencies for which law or legal order authorizes a new use or sharing of the information after this Notice was given. Page 116 (7/97)