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LG213 <br />(Rev. 6/1292) <br />Minnesota Lawful Garnbiing <br />Gambling Manager Affidavit <br />(Attach to the Gambling Manager Application. Form 1.6212) <br />STATE OF Minnesota <br />ss. <br />COUNTY OF Ramsey <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 />I, Betty M. Strohbeen , under oath state that: <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, thett,,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 />InTh day of <br />5eU <br />County <br />9 <br />•440. }.J bit P <br />Notary Public <br />re <br />Oeneen Mad* VI naloA <br />NOTARY Pueuc - <br />0 <br />ANOKA UNTY <br />conunisson <br />JanuuY al. 1000""` <br />Page 3 <br />gnatu of applicant - gambling manager) <br />Lake Owasso Residence Volunteer <br />(Name of organization) Council <br />A- 01414 <br />License number <br />/larle Vionato <br />uauc • O A <br />ANOKA COUNTY <br />My Commlaalon Ex*SS <br />January 91. 2000 <br />