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LG2Y3 <br />(10/15)90) <br />Minnesota Lawful Gambling <br />Gambling Manager Affidavit <br />(Attach to the Gambling Manager Application, LG212) <br />STATE OF �%�Y1 { %1 (J S nT(u ) <br />) s.s. <br />COUNTY OF R (1 M S L G ) <br />AFFIDAVIT OF QUALIFICATION <br />FOR GAMBLING MANAGER LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.16 Subd. 2(e) <br />I, ,B tcL L P1 St k n n b c e /) , under oath state that: <br />I (type /print name) <br />1. I have never been convicted of a felony. <br />2. I have not, within five years, committed a violation of law or board rule that resulted in the <br />revocation of a license issued by the Lawful Gambling Control Board. <br />3. 1 have never been convicted of a criminal violation involving fraud, theft, tax evasion, <br />misrepresentation, or gambling. <br />4. I have never been convicted of assault, a criminal violation involving the use of a firearm, <br />or making terroristic threats. <br />In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject <br />matter of the attached gambling manager license, or acts or omissions arising from such application, may <br />be commenced against me in any court of competent jurisdiction in Minnesota by service on the Minnesota <br />Secretary 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 conduct a <br />criminal background check or review and to share the results with the Lawful Gambling Control Board. <br />Failure to provide required information or providing false or misleading information may result in the denial <br />or revocation of the Iic- MELOD[E X. ORLANDO <br />yay"fl NOTARY PUBLIC— MINNESOTA <br />RAMSEY COUNTY <br />MY COMM. EXPIRES MAY 29, 1991 5 <br />Subscribed and sworn % enjisivva' & / yi sed, ,, 7 / <br />(S(gnatu of applicant - gambling manager) <br />LAXE OWASSU RESIDENCE VOLUNTEER COUNCII. <br />1Suk- <br />County <br />day of -1 C\ 19 9 1 <br />Clir+N4o <br />V crgt \C . 0a.-, <br />Notary Public <br />My commission expires <br />Page 75 <br />(Name of organization) <br />- 0/y7V -OCR <br />License number <br />