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<br />rimed: 12/01197 BINGO HALL PERSONl\'EL INFORLVIATION - LG315
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<br />License Number: BH013 Name of Employer: Pot O'Gold
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<br />Name of Applicant: Goldie Siedow
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<br />OATH and CONSENT STATEMENT .
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<br />1. I have never been convIcted ot a telony, or a crime involving gambling.
<br />2. I have never been convicted of assault, a criminal violation involving the use of a firearm, or making terroristic threats.
<br />3. I am not currently or have ever been engaged in or connected with an illegal business.
<br />4. I do not owe $500 or more in delinquent taxes to the state of Minnesota.
<br />5. [have not had a sales and use tax permit revoked by the commissioner of revenue within the last two years,
<br />6. I have fited, after demand, tax returns required by the commissioner of revenue.
<br />7, [will nmdirectly or indirectly give gifts, trips, prizes, loans of money,!remiums, or other gratuities to gambling
<br />organizations, or their employees, other than nominal gifts not wexcee a value of $25 per organization In a
<br />calendar year.
<br />8, I am not a wholesale distributor of alcohoiic beverages or an employee of a wholesale distributor of
<br />alcoholic beverages.
<br />9. I am not a licensed manufacturer or affLliate of a manufacturer under Minnestoa Statute 349,163,
<br />10. I am not a licensed distributor or affiliate of a distributor under Minnesota Statute 349.161.
<br />1 I. I will not provide any staff to conduct or assist in the conduct of bingo or any other form of lawful gambling
<br />on the premIses.
<br />12. I will not acquire gambling equipment or provide inventory control for any organization that conducts lawful gambling
<br />on the premIses.
<br />13. I will not prepare or assist in the preparation of any reportS required by Minnesota Rule 7861.0120, Subp. 3, for an
<br />organization conducting (awful gambling on the premises.
<br />14. I will not provide accounting services to any organization conducting lawful gabmling on the premises.
<br />15. [wilt not solicit, suggyst, encourage or make any expenditures of any organization's gross receipts from lawful gambling.
<br />16. I will not charge any tee to a person without whIch the person could not play bingo or participate in another form of lawful
<br />gambling on the premises,
<br />17. 1 will not provide assistance or participate in the conduct of lawful gambling on the premises.
<br />18. [will not permit more than 21 hingo occasions to be conducted on the premises in any week,
<br />19. I will not be involved in the procurement of, or intluencing the procurement of, lawful gambling equipment for an
<br />organization which conducts lawful gambling on the licensee's premises.
<br />20, I will not provide or permit an affiliate or person acting on behalf of the bincro hall licensee to provide any
<br />compensatIOn, gift, gratuity, premium, conrribution, or thing of value to a d'ambling Control Board employee or
<br />member of the Camhling Control Board,
<br />21. I will not recruit a person to become a gambling manager or assistant gambling manager or idemify to an organziation a
<br />person as a candidate to become a gambling manager or assistant gambling manager.
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<br />any information submitted in the application changes during the term of the license period, the Bingo Hal! applicant or licensee .
<br />ust notify the board and the appropnate loca! unit of government under Minnesota Statute 349.213, Subd 2, In writing within ten (10) da
<br />o' the change.
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<br />I addition, I understand, agree and hercby irrevocably consent that suits and actions relating to the subject matter of the Bingo Hall
<br />;ense application, or acts or omissions arising from such application, may be commenced against me in any court of competent jurisdiction
<br />Minnesota by service on the Minnesota Secretary of State of any summons, process, or pleading authorized by the laws of Minnesota.
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<br />'/ signature of this document, the undersigned authorizes the Departmcnt of Public Safety to conduct a criminal background check or review
<br />:d to share the results with the Minnesota Gambling Control Board.
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<br />tilure to provide required information or providing false or misleading information may result in the denial or revocation of the license.
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<br />URTHER AFFIANT SA YETH NOT, except that this Oath and Consent Statement are submitted in support of the
<br />)plication for a Bingo Hall license from the Minnesota Gambling Control Board.
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<br />Subscribed and sworn to ~fore me this ~ '~d '
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<br />lib day of <. I ClflUOJ""'J-- 194% ,f)..-flul / d,{)"Jo)
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<br />ffn . - U ignature of ap Ie nt
<br />County of DK....c:^--
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<br />9; . /} ~ 1-1C-f-9%'
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<br />U/l o/!.fl ,--;n. JOS- v../71'-y;rJ Date Signed
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<br />Notary Public l~_# ,
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<br />., ':=J L~~';'. JULIANNE M TOSTE~ISON
<br />My comrmSSLOn exptres =- (,C)O ,t,:,,~~, 'OTARYPUBllC-MINNESQTA
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<br />~ "' ~,. ,,~:'~ 'v'J C~m"" Exc ;~O~3~~~11;1J
<br />le Information requested on this form wLIl be used by the Gamblmg Control1Bo~F(f-{GGB-~-<leti.Fmina . e with Minnesota Statutes and rules
<br />Iverning lawful gambling activities. AU of the informacion that you supply on this fOfm will become public information when received by the GCB except
<br />required, your Social Security number. which remains private.
<br />Disclosure of Social Security Number
<br />ou are required to provide your Social Security number on this form. Your Social Security number will be llsed to determine your compliance with tax .
<br />ws of Minnesott. Authorization for requiring your Social Security number is found at 42 U .S.C. 405 (c)(i).
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