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LG213 <br />(Rev. 6/12/92) <br />STATE OF k i n n c 5; a <br />Minnesota Lawful Gambling <br />Gambling Manager Affidavit <br />(Attach to the Gambling Manager Application, Form LG212) <br />COUNTY OF 2a- ,.,t..i <br />) s.s. <br />I, 5J,zg6'9-7.4 lout se Ind d <br />(type /print name) <br />1. I have never been convicted of a felony. <br />AFFIDAVIT OF QUALIFICATION <br />FOR GAMBLING MANAGER LICENSE <br />AND CONSENT STATEMENT <br />(Pursuant to Minnesota Statute 349.16 Subd. 2(e) <br />and Minnesota Rule 7861.0030,Subp. 12B(3)) <br />under oath state that: <br />2. I have not, within five years, committed a violation of law or board rule that resulted in the <br />revocation of a license issued by the Lawful Gambling Control Board. <br />3. I have never been convicted of a criminal violation involving fraud, theft, tax evasion, <br />misrepresentation, or gambling. <br />4. I have never been convicted of assault, a criminal violation involving the use of a firearm, <br />or making terroristic threats. <br />5. I am not an assistant gambling manager for any other organization. <br />6. I am not a gambling manager for any other organization. <br />In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject <br />matter of the attached gambling manager license, or acts or omissions arising from such application, may <br />be commenced against my organization and I will accept the service of process for my organization in any <br />court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, <br />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 <br />criminal 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 <br />or revocation of the license. <br />Subscribed and sworn to before me this <br />Co "" day of Jf.,.,-)A,s-,,-/ <br />199-1 <br />County <br />Notary Public <br />My commission expires 2-- 11 <br />r <br />CHC,USTIP ELLEN SCHMIDT <br />- MINNESOTA 1{ <br />RAMSEY COUNTY <br />!.iMia !ON EXPIRES 02-11 -97 <br />Page 11 <br />F1 r-2( Gc ie -Ct. /X <br />(Signature of applicant - gambling manager) <br />k)orttis�b�re., <br />(Name of organization) <br />4- aly2s <br />License number <br />