12-12-1990 Additions - Laserfiche WebLink

Home Browse Search

LG200B (9/5190) Minnesota Lawful Gambling Organization Officers Affidavit STATE OF -7- rir2.e. ^moo' " ) AFFIDAVIT OF QUALIFICATION s.s. OF OFFICERS FOR ORGANIZATION LICENSE COUNTY OF r!7 .,�-7-izo-e":". ) AND CONSENT STATEMENT (Pursuant to Minnesota Statute 349.16, Subd. 2e) 1, Raymond G. Harsnn under oath state that within the previous five years: (type /print name) 1. I have not been convicted in a federal or state court of a felony or gross misdemeanor. 2. I have never been convicted of a crime involving gambling. 3. I have not had a license issued by the Lawful Gambling Board or Director revoked for a 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 attached organization license application, or acts or omissions arising from such application, may be commenced against me in any court of competent jurisdiction in Minnesota by service on the Minne- sota Secretary of State of any summons, process or pleading authorized by the laws of Minnesota. 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 Lawful 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 attached application for an organization license from the Lawful Gambling Control Board. Subscribed and sw/oom, to before me this %4 day of LgcP ,,aW c/ 19 /�6f 6,)„, Notary Public gnature of applicant) Chief Executive Officer Treasurer North Raman« K nc Club Name of Organization License Number rapasseneessanapene NOTARY FREEMAN RAMSEY COUNTY My nom union &Ora 12404 Page 30