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LG213 Minnesota Gamb ling Control Board <br />04/18/95 <br />Gambling Manager Affidavit <br />Attach to the Gambling Manager Application, Form LG212 <br />STATE OF t% //v//5o? /n- ) <br />COUNTY OF p`A- -frj f, y ) <br />1, 5U, C.- //r Y F/)-'G //3-A4under oath state that: <br />(type /print name) <br />) s.s. <br />AFFIDAVIT OF QUALIFICATION <br />FOR GAMBLING MANAGER LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statutes and Rules) <br />1. I have never been convicted of a felony or a crime involving gambling. <br />2. I have not, within five years before the date of the license application, committed a violation of law or <br />Board rule that resulted in the revocation of a license issued by the Board. <br />3. I have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, <br />or gambling. <br />4. I have never been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (ii) <br />making terroristic threats. <br />5. I am not, nor ever have been connected with or engaged in an illegal business. <br />6. I do not owe $500 or more in delinquent taxes as defined in section 270.72. <br />7. I have not had a sales and use tax permit revoked by the commissioner of revenue within the past two <br />years. <br />8. I have never, after demand, failed to file tax returns required by the commissioner of revenue. <br />In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject <br />matter of the attached gambling manager license application, or acts or omissions arising from such applica- <br />tion, may be commenced against my organization and I will accept the service of process for my organiza- <br />tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any <br />summons, process or pleading authorized by the laws of Minnesota. <br />By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a <br />criminal background check or review and to share the results with the Gambling Control Board. <br />Failure to provide required information or providing false or misleading information may result in the denial or <br />revocation of the license. <br />FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in <br />support of the application for a gambling manager license from the Gambling Control Board. <br />NOTARY PUBLIC INFORMATION <br />Notary Public Seal must be current and correct. <br />Seal may not be altered. <br />Subscribed and swo <br />day of <br />o before me this <br />19 96 <br />v <br />g nnNNnn ,n,^�n�,�/\ �{,,AV ANA+ <br />itfirgLEVP'R: GLANZER <br />NOTARY PUBLIC-MINNESOTA <br />RAMBEY COUNTY <br />MY Comm, Balm daR, O }, MAW <br />• VUWVVVVVVVVVVVVVVVVVVVVVVVVVVVVV VUa <br />Page 21 <br />(sign .ture of applicant) <br />C <br />ORGANIZATION INFORMATION <br />Name of Organization <br />7-L. CA-A" /3-.0 G /9- ,c• Pcm /tt.✓ <br />L7 /-4-%5 <br />Base License Number <br />