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LG200B (7/28/92) Minnesota Lawful Gambling Organization Officers Affidavit STATE OF Minnesota ) AFFIDAVIT OF QUALIFICATION s.s. OF OFFICERS FOR R a m s e ORGANIZATION LICENSE COUNTY OF y ) AND CONSENT STATEMENT (Pursuant to Minnesota Statute 349.16, Subd. 2e) I Richard Edward Boss,III 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 application, may be commenced against my organization and I will accept the service of process for my organization in any court of competentjurisdiction in Minnesota by service on the Minnesota Secretary 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 conduct 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 revoca- tion of the license. FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the application for an organization license from the Lawful Gambling Control Board. NOTARY PUBLIC INFORMATION Notary Public Seal must be current and correct. Seal may not be altered. Subscribed and sworn to before me this day of 19 /33 Notary Public Page 7 (signature of applicant) APPLICANT INFORMATION /33 Chief Executive Officer i3 Treasurer • Effective date of officer change 01 /01 Horne Address 57 East Bryan City Little Canada State Zip MN 55117 Phone (612 484 -5797 Date of Birth November 8, 1942 Name of Organization Little Canada Volunteer Fire License Number 00864 ept.