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LG213 Minnesota Gambling Control Board <br />04/18/95 <br />Gamb ling Manager Affidavit <br />Attach to the Gambling Manager Application, Form LG212 <br />STATE OF MINNESOTA <br />COUNTY OF RAMSEY <br />JoAnn Margaret Sherman <br />) s.s. <br />, Under oath state that: <br />AFFIDAVIT OF QUALIFICATION <br />FOR GAMBLING MANAGER LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statutes and Rules) <br />(type /print name) <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 (iii) <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 $500 or more in delinquent taxes as defined in section 270.72. <br />7. I have not had a sales and use tax permit revoked by the commissioner of revenue within the past two <br />years. <br />8. I have never, after demand, failed to file tax retums required by the commissioner of revenue. <br />In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject <br />matter of the attached gambling manager license application, or acts or omissions arising from such applica- <br />tion, may be commenced against my organization and I will accept the service of process for my organiza- <br />tion in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any <br />summons, process or pleading authorized by the laws of Minnesota. <br />By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a <br />criminal background check or review and to share the results with the Gambling Control Board. <br />Failure to provide required information or providing false or misleading information may result in the denial or <br />revocation of the license. <br />FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in <br />support of the application for a gambling manager license from the Gambling Control Board. <br />NOTARY PUBLIC INFORMATION <br />Notary Public Seal must be current and correct. <br />Seal may not be altered. <br />Subscribed and swom to before me this <br />/91"- ay of February 19 <br />96 <br />ota�y1§0i.i. FAHEY <br />�.- :'37.'76'a<'•' NoT%RY;unit- MINNESOTA <br />j RAMSEY COUNTY <br />' MrmmmI.,innO„o-f I$I4O n <br />Pa <br />e 67 <br />(signature of applicant) <br />ORGANIZATION INFORMATION <br />Name of Organization <br />Little Canada Charity Plus, Inc <br />Base License Number <br />00393 <br />