|
<br />....Ii..ngo Hall Personnel Information - LG315
<br />
<br />W:ense number: BH013 Name of person:
<br />
<br />Oath and Consent Statement
<br />1. I ha~ never been convicted of a
<br />fElony.
<br />2. I ha'loe never been convictEd of a crime
<br />involving gambfing.
<br />3. I have never been convictEd of assault,
<br />a criminal violatbn involving the use of
<br />a firmrm, or maJdng lErroristic threats.
<br />4. I am not rurrently or have neve- been
<br />engaged in or conneclEd with an i1<>;Jal
<br />business.
<br />S. 1 do not owe $500 or more in
<br />delinquent taxes to the state of
<br />Minnesota.
<br />6, 1 have not had a sales and U5e tax
<br />pennit revoked by the commissioner of
<br />revenue within the last two years.
<br />7. 1 have filed, 1fter demand, tax
<br />returns rB:Iuired by the rommissioner of
<br />revEJlue.
<br />8. 1 am not a ficensed distlibutor or
<br />affifiale of a distributor under Minn.
<br />stat. sec. 349.161.
<br />9. 1 am not a ficensed manufacturer or
<br />affifiat:e of a manufacture- under Minn.
<br />stat. see. 349.163,
<br />1....1 not be an officer, d'wector, paid
<br />~Ioyee, orvolunteer of a licensed,
<br />exempt, or exdJded organization in its
<br />conduct of lawful gambling, or
<br />represent a &censed, exempt, or
<br />exckxled organization In the purchase
<br />of or inft uence the purchase ot lawful
<br />gambfing equipment.
<br />11. 1 am not a wholesale distributor or an
<br />amOale or an employee of a wholesale
<br />disbibutor of alcohoHc beverages.
<br />12. 1 wil not provi:le any staff to conduct or
<br />assist in ttle conduct ot bing:> or any
<br />other form of lawful gambing on the
<br />premises.
<br />13. 1 wiD not acquire gambling equipment
<br />or provi:le inventory control for any
<br />organization that conducts lawful
<br />gambing on the premises.
<br />14. I wi! not prepare or assist in the
<br />preparation of any reports required by
<br />Minn. Rules, part 7861.0120, subp. 3,
<br />for an organization conducting lawful
<br />gambting on the premises.
<br />is. I wiD not provide ao:ounting services to
<br />any organization conducting lawful
<br />gambling on the premises.
<br />16. I win not sofidt, suggest, encourage, or
<br />make any expenditures of an
<br />.aniZationt 5 gross receipts from lawful
<br />mbling.
<br />17. 1 wift not charge any fee to a person
<br />without which ttle person could not play
<br />bingo or par1idpale in another!Onn of
<br />Icwful gambling on the premises.
<br />18. I wiR not provi::le assistance or
<br />participate in the conduct of lawful
<br />gambing on the premises.
<br />
<br />..
<br />
<br />Goldie Katherine Siedow
<br />
<br />19. I wiD not permit more than 11 bingo
<br />occasions to be conducted on the
<br />premises in any week.
<br />20. I wi. not recruit a person to become a
<br />gambling mancger or assistant gambling
<br />manager or iclentify to an organization a
<br />person as a candidate to become a
<br />gambling man;:ger or assistant gambling
<br />manager.
<br />21. I wi. not be involved in the procurement
<br />of, or influencing the prOClD'"ement of,
<br />I....fill gambling equipment !Or an
<br />organization which corK:Iu:t.s lawful
<br />gambling on the li:ensee's premises.
<br />22. I wiB not provide or permit an afiliate or
<br />person acting on behalf of the bing:> haft
<br />Ucensee to provide any compensation,
<br />gift, gratuity, premium, contribution, or
<br />thing of value to a Gambling Control
<br />Board empio"", or manber of the
<br />G<mbling Control Board.
<br />23. 1 wil not diroctly or indirectly give gifts,
<br />trips, prizes, loans of money, premiums,
<br />or other gratuities to gambling
<br />organizations, or their employees.. other
<br />than nominal gifts not to exceed a value
<br />of $25 per oryaniz2tion in a calendar year.
<br />
<br />~~~L~~~L)
<br />
<br />(Signature of bingo aD nnel apphc1<11)
<br />1Ut.M)~
<br />
<br />Cou nty of
<br />be!Ore me this~ day of
<br />Notary Pubic: )J.oJ ,q ,
<br />My commission eXPires:..lJ---2L~
<br />
<br />In addition, 1 understand, <gree, and herEDY
<br />irreJocably consent that suits and actions
<br />relating to ttle subject matter of the bingo haft
<br />license appli:::ation, or acts or omissions
<br />arising from such appHcation, may be
<br />commenced against me in any court of
<br />competEnt jurisdiction in Minnesota by service
<br />on the Minnesota secretary of State of any
<br />summons, process, or pleading authorized by
<br />ttle laws of Minnesota.
<br />Bysignature of this doaJrnent, the undersigned
<br />autholizes ttle Department of Publi: Safety to
<br />conduct a background investigation pursu1<1t to
<br />Minnesota Rules, part 7862.0010, subpart lOa,
<br />By signature of this doannent, the undersigned
<br />attests that information pro\lided in this
<br />application is true and correct. Failure to
<br />provKle required information, or provKling false
<br />or misleading infurmation, may result in the
<br />denial or relocation of the ticense.
<br />Changes in application infonnatbn will be
<br />submitted within tEn days.
<br />
<br />FURlliER AFFIANT SAYElH NOT, except that
<br />this Oath and Consent St<tement is submitted
<br />in support of ttle application for a bingo hall
<br />Ii:ense from the Gambing Control Board.
<br />
<br />./dJ .Mi1ll...
<br />Dale signed
<br />
<br />SUbscrlbed and sworn to
<br />
<br />
<br />20 O;A .
<br />
<br />The infonnation requested on this form (and any iIj:<K:h~nts) v.M1 be used by the Ganbling Control Board
<br />(Board) rodetermine your qualifICations to be invclved in lawful ganbling acti\tities In MInnesota, m to assist
<br />the Board in conducting a background investigation of l<lu. You have a right to refuse to supply the
<br />jnformation requested; however, jf you refuse to supply this intonnatioo, the Board may not be iDle tD
<br />determine }Qur qualifICations ald.. as a consequence, may rduse to register you. If ~u supply the information
<br />requested. the Board will be able to register 'rOu. You are required to prtl\'ide your sodaf seaJrit)t number on
<br />this fonn. Yoursociat seaJrity number will be used todEterrrine youroompliance with thet~ law; of
<br />Minnesota. Authorizction fi:lr requiling your social seaJrtty nurrber is found at 42 U.S.C. 4)5 (cXi). Your name
<br />and address will be public information when received by the Board. AJI the other information that you pro'lide
<br />will be privcte data about ',QU until the Board approves your registration. When the Board approvesyour
<br />registration, all of the infonnation that you ha~ provided to the Board in the process ri rfl'.Jlsterlng wfU berome
<br />public E!l(cept for your social security number, which rermins private, lfthe Board does not ~proW! your
<br />~istration, aU the information you haole prcMded in the process of registering remains private, with the
<br />'e)lJ:eption of your name and address, which will remain public. Privite data about you are avaOable omy to the
<br />follOWing: Board m:-mbefS, stiif of the Board whose mrk assignment require; that they hale aa:ESS to the
<br />information; the Minnesota Department of Public SafEty; the Minnesota Attorney General; the Minnesota
<br />Cnmmissioners of Mministrition, FJnance, and RevEnJe; the Minnesota legislative Auditor; national and
<br />intemctiQnal gambling regulatory agencies; anyone pursuant to court order; other individuals and agencie5~t
<br />are spedflCally authCJ"ized by state or federal law to ha~ access to the information; individuals and c.;jenciesfor
<br />which law or legal CJ"der authorizes a new use or sharing of informction after thi snctice was givm; lIld anyone
<br />
<br />with your vvritten consent.
<br />
|