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<br /> . LG316 Minnesota Lawful Gambling <br /> (lOI30f.IQ) Bingo Hall Personnel Mfidavit <br /> STATE OF /h/.I//Y~ Sol-/( ) AFFIDAVIT OF QUALIFICATION <br /> . ) S.s. FOR BINGO HALL LICENSE <br /> AND CONSENT STATEMENT <br /> (Pursuant to Minnesota Statute 349.164) <br /> I, '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. f will not acquire, provide storage control or inventory control, or report the Use of any gambling equipment <br /> used by an organization that conducts lawful 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 fawful 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 /> oflhe 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.4/~~~ <br /> (Signature of applicant - Bingo Hall Personnel) <br /> ,dn/, #' /1;/15 !3 /11/'.-" JI,// <br /> , . <br /> Name of Bingo Hall <br /> . 0/3 <br /> d 'd~-qq Bingo Hall License Number <br /> My commission expires <br />