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LG2002 <br />(7/24/91) <br />Minnesota Lawful Gambling <br />Organization Officers Affidavit <br />STATE OF M. (N N Csn t P ) <br />) s.s. <br />COUNTY OF PP-M` Etdc ) <br />L fAM eMi 65.12-0 -v-T <br />(type /print name) <br />AFFIDAVIT OF QUALIFICATION <br />OF OFFICERS FOR <br />ORGANIZATION LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.16, Subd. 2e) <br />Wo a $ -a -,-- , under oath state that within the previous <br />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 />day of \/ -EwE _19 1 <br />RISTIN P. VANSCHOONHOVEN <br />NOTARY PLOW • MINNESOTA <br />MVCOOWn ECW_JanN 0. LSW <br />e ,Ali_40I'.41 <br />(signature of applicant) <br />❑ Chief Executive Officer a Treasurer <br />ka7- - /7 a-ao <br />Name of Organization <br />14— c/e- .2 1/ <br />License Number <br />Page 39 <br />pia <br />