11-27-1991 Council Agenda - Laserfiche WebLink

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LG200n (7/24/91) Minnesota Lawful Gambling Organization Officers Affidavit STATE OF AFFIDAVTT OF QUALIFICATION ) s.s. OF OFFICERS FOR ORGANIZATION LICENSE COUNTY OF ) AND CONSENT STATEMENT (Pursuant to Minnesota Statute 349.16, Subd. 2e) I, S%o 9 a Ph, 4,-y.<y 0,7 .4/.1/ /i..� , under oath state that within the previous (type /print name) five years: 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 Control 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 organization license application, or acts or omissions arising from such applica- tion, 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 Secre- tary 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 con- duct 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 submit- ted in support of the application for an organization license from the Lawful Gambling Control Board. Subscribed and sworn to before me this 0(0 ic4 day of ! fgeS2.19 J ma. M. Engleben NOTARY Pt$UC - i4INNE8OTA RAMSEY COUNTY My aorondSon YphM 619-06 IN Chief Executive Officer 0 Treasurer v? wit e Name of Organization — d /P'?y License Number Page 40