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LG316 Minnesota Lawful Gambling <br />(toOOr90) <br />Bingo Hall Personnel Affidavit <br />STATE OF MINNESOTA ) AFFIDAVIT OF QUALIFICATION <br />s.s. FOR BINGO HALL LICENSE <br />COUNTY OF RAMSEY ) AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.164) <br />I, THOMAS SHORT , under oath state that: <br />(type or print) <br />1. I have not been convicted of a felony. <br />2. I have never been convicted of a crime involving gambling. <br />3. I do not owe delinquent taxes in excess of $500 as defined in Minnesota Statute section 270.72. <br />4. I am not a licensed distributor or affiliate of a distributor under section 349.161. <br />5. I am not a licensed manufacturer or affiliate of a manufadurer under section 349.163. <br />6. I am not a wholesale distributor of alcoholic beverages. <br />7. I will not provide any staff to conduct or assist in the conduct of any lawful gambling on the premises. <br />8. l will not acquire, provide storage control or inventory control, or report the use of any gambling equipment <br />used by an organization that conducts lawful gambling on the premises. <br />9. I will not provide accounting services to any organization conducting lawful gambling on the premises. <br />10. I will not solicit, suggest, encourage or make any expenditures of gross receipts from lawful gambling of <br />an organization. <br />11. I will not charge a fee to a person without which the person could not play a bingo game or participate in <br />another form of lawful gambling on the premises. <br />12. I will not provide assistance or participate in the conduct of lawful gambling on the premises. <br />13. I will not prepare bingo packets. <br />In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of <br />the attached bingo hall license application, or acts or omissions arising from such application, may be commenced <br />against me in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any <br />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 background <br />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 or revocation <br />of the license. <br />FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Stateme t are submitted in sup..rt • the <br />application for bingo hall license application from the Lawful Gambling Control Bo. d. <br />Subscribed and sworn to before me this (Signature of applicant - Bingo Hall Personnel) <br />LITTLE CANADA BINGO HALL <br />day of 19 <br />Notary Public <br />My commission expires <br />Name of Bingo Hall <br />BH -010 <br />Bingo Hall License Number <br />Page 57 <br />