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LG213 <br />(Rev. 6/12/92) <br />Minnesota Lawful Gambling <br />Gambling Manager Affidavit <br />(Attach to the Gambling Manager Application, Form LG212) <br />STATE OF Minnesota <br />COUNTY OF Ramsey <br />) s.s. <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. 128(3)) <br />1, Robert Gordon Johnson ,underoathstatethat: <br />(type /print name) <br />1. I have never been convicted of a felony. <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 />day of May <br />County <br />Igo /// Ay 1 <br />• <br />19 95 <br />Notary P li %]1 <br />My commission expires (,�.tcp . .50, / 9 <br />II AAAAAAAAAAAAAAAAAA'TAAAAAAMMMAM <br />LINDA L. FAHEY <br />NOTARY PUBLIC - MINNESOTA <br />RAMSEV COUNTY <br />My Comm. Expires Aug. 30, 1995 <br />vvw' Pr /vvwvvvVvvvWVwwVVVVyvV <br />(? m,ti <br />(Signature of app Kant - gambling manager) <br />Little Canada Volunteer Fire Dept. <br />(Name of organization) <br />B -00864 <br />License number <br />Page 23 <br />