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LG2008 <br />(9/5/90) <br />STATE OF <br />COUNTY OF <br />Minnesota Lawful Gambling <br />Organization Officers Affidavit <br />s.s. <br />AFFIDAVIT OF QUALIFICATION <br />OF OFFICERS FOR <br />ORGANIZATION LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota <br />Statute 349.16, Subd. 2e) <br />J. reor/ - {ellie under oath statethat <br />within the previous live years: (type /print name) <br />1. 1 have not been convicted in a federal or state court of a felony or gross misdemeanor. <br />2. 1 have never been convicted of a crime involving gambling. <br />3. I have not had a license issued by the Lawful Gambling Board or Director revoked for a <br />violation of law or board rule. <br />In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject <br />matter of the attached organization license application, or acts or omissions arising from such application, <br />may be commenced against me in any court of competent jurisdiction in Minnesota by service on the Minne- <br />sota Secretary of State of any 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 Lawful 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 attached application for an organization license from the Lawful Gambling Control Board. <br />Subscribed and sworn to before me this <br />�� day of �19�O_ <br />Public <br />Page 28 <br />ign re (3f applicant) <br />Vtk Chief Executive Officer _ e � Treasurer <br />North Ramsey Knn +h T;nns Club <br />Name of Organization <br />License Number <br />NOrmY PUBLIC „iftaoA <br />RAMSEY COUNTY <br />fMp a nnfalon s*ss $-1946 <br />