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LG200B <br />(7/24/91) <br />Minnesota Lawful Gambling <br />Organization Officers Affidavit <br />STATE OF NA 1 N‘ N t2'T: 1 1\ ) AFFIDAVIT OF QUALIFICATION <br />) s.s. OF OFFICERS FOR <br />ORGANIZATION LICENSE <br />COUNTY OF t('%N{"\---^ i( ) AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.16, Subd. 2e) <br />I !t J'l►, e-,., of C / /%.rr% 4o r $ -e -v-- , under oath state that within the previous <br />(type /print name) five years: <br />1. I have not been convicted in a federal or state court of a felony or gross misdemeanor. <br />2. I have never been convicted of a crime involving gambling. <br />3. I have not had a license issued by the Lawful Gambling Control 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 <br />subject matter of the organization 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 <br />organization in any court of competent jurisdiction in Minnesota by service on the Minnesota Secre- <br />tary 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 con- <br />duct a criminal background check or review and to share the results with the Lawful Gambling <br />Control Board. <br />Failure to provide required information or providing false or misleading information may result in <br />the denial or revocation of the license. <br />FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submit- <br />ted in support of the application for an organization license from the Lawful Gambling Control <br />Board. <br />Subscribed and sworn to before me this <br />1C-5-clay of t��� t��> 79' <br />RISTW P. VANSCHOCSOTA N <br />4OTM1v PUIIC .4NN[�TA <br />J\ CCAJNTY <br />Cmm lgW.. .W. I <br />4Y q W07 <br />(signature of applicant) <br />❑ Chief Executive Officer at Treasurer <br />Nerf CesaroaS <br />Namc of Organization <br />4— 0 /P7!" <br />Liccnsc Number <br />Page 11 <br />cia <br />