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LG200B <br />(11/19 /90) <br />Minnesota Lawful Gambling <br />Organization Officers Affidavit <br />STATE OF Z/ /t'c• ) AFFIDAVIT OF QUALIFICATION <br />) s.s. OF OFFICERS FOR <br />ORGANIZATION LICENSE <br />COUNTY OF - r ><:.a C ) AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.16, Subd. 2e) <br />I, [, r, 7" / A ! L. , 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 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 attached organization license application, or acts or omissions arising from such <br />application, may be commenced against me in any court of competent jurisdiction in Minnesota by <br />service on the Minnesota Secretary of State of any summons, process or pleading authorized by the <br />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 />BoVAw <br />MELODEE Y. ORLANDO <br />g NOTARY PUB' iC— MiNNESOTA <br />S ��.1'�� RA,4':SEY CGUNr( <br />MY COMM. EXPIRES MAY 29, 1991 <br />y � <br />Subscribed and sworn to before me this <br />\-34\ day of `"l' `titit-k. 19 C <br />1 <br />nature of applicant) <br />12. Chief Executive Officer ❑ Treasurer <br />N1 OWASSU RESIDENCE VOLUNTEER COUNCU <br />Name of Organization <br />�? ' /z/ 717 ('z.) <br />Notary Public License Number <br />Page 74 <br />