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LG213 Minnesota Lawful Gambling (Rev. 7/18/97) Gambling Manager Affidavit (Attach to the Gambling Manager Application, Form LG2I2) AFFIDAVIT OF QUALIFICATION FOR GAMBLING MANAGER LICENSE AND CONSENT STATEMENT (Pursuant to Minnesota Statute 349.16 Subd. 2(e) I , under oath state that: (type /print name) 1. I have never been convicted of a felony. 2. I have not, within five years, committed a violation of law or board rule that resulted in the revocation of a license issued by the Lawful Gambling Control Board. 3. I have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. I have never been convicted of assault, a criminal violation involving the use of a firearm, or making terroristic threats. In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of the attached gambling manager license, or acts or omissions arising from such application, may be commenced against my organization and I will accept the service of process for my organization in any court of competent jurisdiction in Minnesota by service on the Minnesota 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. Subscribed and sworn to before me this �0 /4 day of 1-xzei-n4l4v 19 V 4/ Not.yA t commission expires /9QG Joya NOTARY Pt.FU SE•PtOTA RAMSEY COUNTY My commtmice s 8-10-9e i (Signature of applicant - gambling manager) x fi r ,ye ripe—ee (Name of organization) r License number Page 10