Laserfiche WebLink
APR -21 -s4 I ttu '114 48 :29 <br />LG316 <br />(10(3080) <br />TCF BANK 708 571-4013 <br />WI' BANK FAX NO. 612 338 6042 <br />Minnesota l atyf l Gambling <br />Bingo 'Hall Personnel. Affidavit <br />STATHOF Illinois <br />COUNTY OF DuPage <br />) <br />P.2 <br />P. 03 <br />AFFIDAVIT OF QUALIFICATION <br />a,a. ' FOR BINGO HALL LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute :349.164) <br />Jeffrey Todd Doering • under oath state that: <br />(type or print) <br />1. 1 have not been convicted of a felony. <br />2. I have never been Convicted era crime involving gambrutg. <br />• 3. I do not owe delinquent taxes in excess of $500 as.defined in' Minnesota Statute•aedion 270.72. <br />4. 1 am not a licensed distrbutot or affiliate at a distributor under section 349.161. <br />.5.' tam not a licensed manufacturer or affiliate of a manufacturer under sedan :349.163. <br />6. I am not a wholesale distributor di alcoholic beverages. <br />.7. I will hot provide any staff to conduct ar assist in•the conduct of any Iawlui gambling on the premises, , <br />8. I will not acquire; providestorage°antral or inventory control, or report the ore of any gambling equipment <br />used by an organization that conducts lawful gambling on the premises. <br />9. 1 will not provide accounting services to any organization conducting lawful gambUng'on the premises, <br />• <br />10. I will not solicit, suggest, encourage or make any expenditures of gross rece pta from lawful gambling 01 <br />an organization. <br />11. • i will not charge a fee to a potion without which the person mold not playa Dingo game or. participate to <br />another form at lawful gambling on the premises. <br />• 12. I'w9I not provide assistance or participate in the conduct of lawful gambinp On the premises.• <br />13. 1 will not prepare bingo packets. " <br />to addition. I understand, agree and hereby irrevocably consent that suits and ac4ane relating to the subject matter of <br />the attached bingo hap license application, or ads or omissions edging from such application, may be commenced <br />against me in any court of competent jurisdiction in Minnesota by service on the•Mlnr,esota Secretary of State ol•any <br />summons, process or pleading authorized by the lawsaf 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 />• <br />Faaure to provide required Information or providing-faise or misleading information. may reauftin the denial or revocation <br />at the license. <br />FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted instrppo 1 of the <br />application for bingo hall license application from the Lawful Gambling Control Board. <br />• <br />• <br />• <br />OFFICI•AL SEAL " <br />LORI R. SCHNEIDER <br />Subscnbad and sw N T y PUBL��I�,.•�7ATE OF ILLINOIS <br />UMiSiMPOPINES 6/29/96 <br />nL/ yr' day of <br />• <br />/t <br />• <br />Notary Public. <br />My commission expires 6 <br />629 <br />;F•IN'cIOEFf <br />.,'AIE OF ILLINOIS <br />.1XPIRES 6/29/96 <br />The Market: PI. <br />Name of Bingo Hall <br />' BH -040 ' <br />Bingo Hall License Number <br />Page 111 <br />• <br />