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<br /> LG316 Minnesota Lawful Gambling <br /> (tal3ana) Bingo Hall Personnel Mfidavit <br /> STATE OF k/I/JY'<' 5oJ.-/( ) AFFIDA VIT OF OUALlFICA TION <br /> . } S.s. FOR BINGO HALL LICENSE <br /> COUNTY OF /1-1 J?/7( y:'/ ~ ) AND CONSENT STATEMENT <br /> (Pursuant to Minnesota Slat ute 349,164) <br /> I, E/;/'") /JJ- 1l tNo0/,~c./;;j, , under oath state that: <br /> (type or print) <br /> 1. I have not been convicted of a felony. <br /> 2. I have never been convicted of a crime involving gambling, <br /> 3, I do not owe delinquent taxes in excess of $500 as defined in Minnesota Statute section 270,72, <br /> 4, I am not a licensed distributor or affiliate of a distributor under section 349.161. <br /> 5. I am not a licensed manufacturer or affiliate of a manufacturer under section 349,163. <br /> 6, I am not a wholesale distributor of alcoholic beverages. <br /> 7. I will not provide any staff to conduct or assist in the conduct of any lawful gambling on the premises, <br /> 8. I will not acquire. provide storage control or inventory controi, or report the use of any gambling equipment <br /> used by an organization that conducts iawful gambling on the premises. <br /> 9. I will not provide accounting services to any organization conducting lawful gambling on the premises, <br /> 10. i will not solicit, suggest, encourage or make any expenditures of gross receipts from lawful gambling of <br /> an organization. <br /> . 11. I will not charge a fee to a person without which the person could not playa bingo game or participate in <br /> another form of lawful gambling on the premises, <br /> 12, I will not provide assistance or participate in the conduct of lawful gambling on the premises, <br /> 13, I will not prepare bingo packets. <br /> In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of <br /> the attached bingo hall license application, or acts or omissions arising from such application, may be commenced <br /> against me in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any <br /> summons, 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 background <br /> 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 or revocation <br /> of the license. <br /> FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the <br /> application for bingo hall license application from the Lawful Gambling Control Board. <br /> Subscribed and sworn to before me this d~~~;L~ <br /> (Signature of applicant - Bingo Hall Personnel) <br /> , 4nj, # /It lis /3; /f/;~; /1,// <br /> Name of Bingo Hall <br /> . 0/'5 <br /> ;)rd-tj-q~ Bingo Hall License Number <br /> My commission expires <br />