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<br />OCT-28-21211213 15:19 FROM:MRRY RUE SCHUTTR CPR 7637841729
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<br />TO:551 483 862121
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<br />'. ~., ':i,:<'~?~.~al: ~a~~~in9.,;Man~~~r,:~~c~nse{F~e.'$~OO)
<br />GM License #: 01816-005
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<br />Gambling Manager:
<br />Home Address:
<br />Phone:
<br />Date of Birth:
<br />Social Security #:
<br />Bonding Insurance Co:
<br />Bond #:
<br />Most Recent Education:
<br />
<br />John Dennis Deppa
<br />2056 129th Ct NE, Blaine, MN 55449
<br />(763) 767-4981
<br />2/28/1944
<br />477~48-8320
<br />United Fire & Casualty
<br />51072998
<br />6/25/2003
<br />
<br />~!.
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<br />I----------------------------------------~
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<br />IfD We will not be renewing this person as gambling manager. Enclosed is a separate LG212 application
<br />Note: A new gambling manager may not assume duties until licensed by the Gambling Control Board.
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<br />.. .'.. ". ~:;", ~:.. .. '. .r,' oj ',: Affidavit-iir1d"Consenf.statemetit;li;: . ,;.":. ;~>, ,.
<br />. ,: j -. ..:.~':':-"~:'. ~.... .~~.:~:::.';:' r~:.~,.:; ..-~;"":~:. .:;::;.::IJ.~::'::~;':"5.. :':J,:;.:" -':<~.....,'.'.~:~::\<:::.l:;:":::':::~-
<br />
<br />L I have never been convicted of a felony or a crime
<br />Involving gambling.
<br />2. I have never committed a violation of law or Board
<br />rule that resulted in the revocation of a license issued
<br />by the Board within five years before the date of the
<br />license application,
<br />3. I have never been convicted of a criminal violation
<br />involving fraud, theft, tox evasion, misrepresentation, Or
<br />gambling.
<br />4. I have never been convicted of (i) assault, (ii) a
<br />criminal violation involving the use of a firearm, or (iii)
<br />making terroristic threats.
<br />5. I have never been, or am I now, connected with or
<br />engaged in an illegal business.
<br />5. I have never had a sales and use tax permit revoked
<br />by the commissioner of revenue within the past two
<br />years.
<br />7. I have neller, after demand, failed to file tax returns
<br />reouired bv the commissioner of revenue.
<br />8. I do not owe $500 or more in delinquent taxes as
<br />defined in section 270.72.
<br />9. I have been an active member of the organization.
<br />10. I am not a gambling manager or an assistant
<br />gambling manager for another organization.
<br />11. I am not a lessor, a member of the immediate
<br />family, or an employee of a lessor of a premises where
<br />this organization has a permit issued from the Board to
<br />conduct lawful gambling.
<br />
<br />12. r am not involved directly or indirectly as a bingo
<br />hall owner, manufacturer, Or distributor.
<br />13. I am not the chief executive officer of this
<br />organization.
<br />14. I am not the treasu~cr of this organization.
<br />
<br />Background Check. By signature of this document, the
<br />undersigned authorizes the Departments of Public Safety and
<br />Revenue to conduct a criminal and tax background check or
<br />review and tp share the results with the Gambling Control
<br />Board. Further, I understand, agree, and hereby irrevocably
<br />consent that suits and actions relating to the subject matter of
<br />this gambling manager license application, or acts or omissions
<br />arising from such application, may be commenced against me
<br />or my organization and I will accept the seT\lice of process 11'1
<br />any court of competent jurisdiction in Minnesota by service on
<br />the Minnesota Secretary of State of any summons, process, or
<br />pleading authorized by the laws of Minnesota.
<br />Failure to provide required information or providing false or
<br />misleading information may result in the denial or revocation of
<br />the license.
<br />
<br />
<br />
<br />Notary
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