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Printed: 12/01/98 BINGO HALL PERSONNEL INFORMATION - LG315 Name of Employer: Pot O'Gold Name of Applicant: Goldie Siedow . OATH and CONSENT STATEMENT 1. I have never been convlcted of a felony, or a crime involving gambling. 2. J have never been convicted of assault, a criminal violation Involving tbe use of a firearm, or making terroristic threats. 3. I am not currently or have ever been engaged in or connected with an illegal business. 4. I do not owe $500 or more in delinquent taxes to the state of Minnesota. 5 ;-j-Imve-not-had-a-sales-and-use-tax-permit--revok-ed-by-the--eOlll1lllssioner-of-r-evenue-within-tbe--Iast-tWe-year-s. 6. I have filed, after demand, tax returns required by the cOlll1lllssioner of revenue. 7. I will not directly or indirectly give gifts, trips, prizes, loans of moneY'lremiums, or other gratuities to llambling organizations, or their employees, other than nominal gifts not to excee a value of $25 per organization m a calendar year. 8. I am not a wholesale distributor of alcoholic beverages or an employee of a wholesale distributor of alcoholic beverages. 9. I am not a licensed manufacturer or affiliate of a manufacturer under Minnestoa Statute 349.163. 10. I am not a licensed distributor or affiliate of a distributor under Minnesota Statute 349.161. II. I will not pI:ovide any staff to conduct or assist in the conduct of bingo or any other form of lawful gambling on the premlses. 12. I will not a~quire gambling equipment or provide inventory control for any organization that conducts lawful gambling on the prenuses. 13. I will not prepare or assist in the preparation of any reports required by Minnesota Rule 7861.0120, Subp. 3, for an organization conducting lawful gambling on the premises. 14. I will not provide accounting services to any organization conducting lawful gabmling on the premises. - 15. I will not solicit, suggest. encourage or make any expenditures of any organization's gross receipts from lawful gambling. 16. I will .not charge any fee to a person without whIch the person could not play bingo or participate in another form of lawful gamblmg on the prenuses. 17. I will nol provide assistance or participate in the conduct oflawful gambling on the premises. 18. I will not permit more than 21 llingo occasions to be conducted on the prenuses in any week. 19. I will not be involved in the procurement of, or influencing the procurement of, lawful gambling equipment for an organization which conducts lawful gambling on the licensee's premises. 20. I will not provide or permit an affiliate or person acting on behalf of the bingo hall licensee to provide any compensatIOn, gift, g~atuity, premium, contribution, or thing of value to a Gambling Control Board employee or member of the Gambhng Control Board. 21. I will not recruit a person to become a gambling manager or assistant gambling manager or identify to an organziation a person as a candidate to become a gambling manager or assistant gambling manager. I.information submitted in the application changes during the term of the license period, the Bingo Hall applicant or licensee must notify the board and the appropnate local unit of government under Minnesota Statute 349.213, Subd 2, m writing within ten (10) days of the change. License Number: BH013 In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of the Bingo Hall license application, or acts or omissions arising from such application, may be commenced against me in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process, or pleading authorized by the laws of Minnesota. By signature of this document, the undersigned authorizes the Department of Public Safety to conduct a criminal background check or review and to share the results with the Minnesota Gambling Control Board. - Failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. FURTHER AFFIANT SA YETH NOT, exc~ that this Oath and Consent Statement are submitted in support of the application for a Bingo Hall license from the innesota Gambling Control Board. ~~ . Subscrib~ and sworn to before me this eJJ l . g - dayof~ 19'1~ 05i~J)~ 0 . (JjU..uJ Signature of appl can County of /f9--d-.f-9? . Notary Public I SHEILA STOWELL My commission expires \ r ':>,i/:>.trC" - NOTARY fUBLtC-MINNESOTA III c......,.. e",I,.. JIll. 31,_ The information requested on this form will be used by the Gambling Co nee with Minnesota Statutes and rules governing lawful gambling activities. All of the information that you supply on this fonn wilt become public information when received by the GCB except if required, your Social Security number t which remains private. Disclosure of Social Security Number ~e required to provide your Social Security number on this form. Y OUT Social Security number will be used to determine your compliance with tax 1~~Minnesota. Authorization for requiring your Social Security number is found al42 U.S.C. 405 (c)(I).