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LG213 <br />(10/15/90) <br />Minnesota Lawful Gambling <br />Gambling Manager Affidavit <br />(Attach to the Gambling Manager Application, LG212) <br />Ireneaus 1. iriassman <br />(type /print name) <br />1. I have never been convicted of a felony. <br />) s.s. <br />AFFIDAVIT OF QUALIFICATION <br />FOR GAMBLING MANAGER LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.16 Subd. 2(e) <br />under oath state that: <br />2. I have not, within five years, committed a violation of law or board rule that resulted in the <br />revocation of a license issued by the Lawful Gambling Control Board. <br />3. I have never been convicted of a criminal violation involving fraud, theft, tax evasion, <br />misrepresentation, or gambling. <br />4. I have never been convicted of assault, a criminal violation involving the use of a firearm, <br />or making terroristic threats. <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, or acts or omissions arising from such application, may <br />be commenced against me in any court of competent jurisdiction in Minnesota by service on the Minnesota <br />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 <br />or revocation of the license. <br />Subscribed and sworn to before me this <br />day of ¢sQ_ igt. 19 90 . <br />County <br />1� <br />,rotary Public <br />My commission expires <br />/796 <br />Page 37 <br />(Signature of applicant - gambling manager) <br />North Ramsey 500th Lions Club <br />(Name of organization) <br />License number <br />