04-27-1994 Council Agenda - Laserfiche WebLink

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LG316 Minnesota Lawful Gambling (10/30,90) Bingo Hall Personnel. Affidavit STATE OF Minnesota ) AFFIDAVIT OF QUALIFICATION s.s. FOR BINGO HALL LICENSE COUNTY OF Hennepin ) AND CONSENT STATEMENT (Pursuant to Minnesota Statute 349.164) Joseph Thomas Green under oath state that: (type or print) 1. I have not been convicted of a felony. 2. I have never been convicted of a crime involving gambling. 3. I do not owe delinquent taxes in excess of $500 as defined in Minnesota Statute section 270.72. 4. I am not a licensed distributor or affiliate of a distributor under section 349.161. 5. I am not a licensed manufacturer or affiliate of a manufacturer under section 349.163. 6. t am not a wholesale distributor of alcoholic beverages. 7. I will not provide any staff to conduct or assist in the conduct of any lawful gambling on the premises. 8. I will not acquire, provide storage control or inventory control, or report the use of any gambling equipment used by an organization that conducts lawful gambling on the premises. 9. I will not provide accounting services to any organization conducting lawful gambling on the premises. 10. I will not solicit, suggest, encourage or make any expenditures of gross receipts from lawful gambling of an organization. 11. I will not charge a fee to a person without which the person could not play a bingo game or participate in another form of lawful gambling on the premises. 12. I will not provide assistance or participate in the conduct of lawful gambling on the premises. 13. I will not prepare bingo packets. In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of the attached bingo hall license application, or acts or omissions arising from such application, may be commenced against me in any court of competent jurisdiction 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 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 revocation of the license. FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the application for bingo hall license application from the Lawful Gambling Control Board. Subscribed and sworn to before me this L—' day of!r19g4 (Signs 11j • of ap icant . Bin gb Hall Personnel) The Market Place Notary Public My commission expires r DONNA L NAM NOTAAYf tNGMINNESOTA HENNEE N COUNTY , My ComNubn BONA 1w. 11.2000 Hall License Number Page 109