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LG200B <br />(7/28/92) <br />Minnesota Lawful Gambling <br />Organization Officers Affidavit <br />STATE OF /72/ // /✓c S- 0 /� ) <br />COUNTY OF 'A/22 f E Y ) <br />AFFIDAVIT OF QUALIFICATION <br />) s.s. OF OFFICERS FOR <br />ORGANIZATION LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.16, Subd. 2e) <br />L 7-84 /V 0/ 4 A/i94,4S-0 4/ under oath state that within the previous <br />( 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 Control 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 subject matter of the <br />organization license application, or acts or omissions arising from such application, may be commenced against my <br />organization and I will accept the service of process for my organization in any court of competent jurisdiction in <br />Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading authorized by the laws of <br />Minnesota. <br />By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a criminal <br />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 or revoca- <br />tion of the license. <br />FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the <br />application for an organization license from the Lawful Gambling Control Board. <br />NOTARY PUBLIC INFORMATION <br />Notary Public Seal must be current and correct. <br />Seal may rant be altered. <br />/% <br />Subscribed and sworn to before me this <br />day of - ' ;41„LA. k 19 f 3 <br />Home g9 I "C/Q )670, -6- /mAO <br />' ...),;/>Seet/L-e-ls,C <br />State 7/1 Zip C Si /7 <br />Notary Public • <br />, TH KaI..EEN A. GLANZER <br />e�, NOTARY PUBLIC-MINNESOTA <br />1}4 RAMSEV COUNTY <br />MY Emil n, F*8I,P.6 OM 4, }ONO <br />FuvvVVVVV VVVvvvvvvvvvvvvvWVVVVVVW r <br />(signature of applicant) <br />APPLICANT INFORMATION <br />Chief Executive Officer • Treasurer "- <br />Effective date of officer change / / <br />Home g9 I "C/Q )670, -6- /mAO <br />City <br />Sr PA u/ <br />State 7/1 Zip C Si /7 <br />Phone (biz) 549V ft y6 <br />Date of Birth <br />/ -.J o -S 0 <br />Name of Organization <br />/VOZ r, &, . �'"Ac -s <br />License Numbe - <br />a/5/74 cc'? <br />Page 49 <br />