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<br />Printed: 12/09/99 <br /> <br />BINGO HALL PERSONNEL INFORMATION - LG31S <br /> <br />License Number: BH013 <br /> <br />Name of Employer: Pot O'GoId <br />Name of Applicant: Goldie Siedow <br /> <br />OATH and C~ENT STATEMENT <br /> <br />1. I have never convIcted of a felony, or a crime involving gambling. <br />2. I have never been convicted of assault, a criminal violation mvolving 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 IOOJe in delinquent taxes to the state of Minnesota. <br />5. I have not had a sales and use tax permit revoked by the commissioner of revenue within the last two years. <br />6. I have filed, after demand, tax returns required by the commissioner of revenue. <br />7. I will not directly or indirectly give gifts, trips, prizes, loans of mon~.;;;.rremiums, or other gratuities to gambling <br />~anizations, or their employees, other thari nominal gifts not to ex a value of $25 per organization m a <br /> <br />8. I a:'= i~olesale distributor of alcoholic beverages or an employee of a wholesale distributor of <br />alcoholic beverages. <br />9. I am not a licensed manufacturer or affiliate 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 />11. I will not provide any staff to conduct or assist in the conduct of bingo or any other form of lawful gambling <br /> <br />onI wilt1>le premi"",!. bl" 'd . I fo . . tha d I wful blin <br />12. not acqu.re gam mg equIpment or prov. e mventory contro r any orgamzallon t con ucts a gam g <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 lawful gambling on the premises. <br />14. I will not pr<lvide accounting selVices to any organization conducting lawful gabmling on the premises. <br />15. I will not solicit, suggest, 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 peniOn could not play bingo or participate in another form of lawful <br />gambling on t1ie premises. <br />17. I will not provide assistance or participate in the conduct of lawful gamblinll on the premises. <br />18. I will not permit more than 21 bingo occasions to be conducted on the prelDlses in any week. <br />19. I will not be involved in the procurement of, or influencing 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 bingo hall licensee to provide any <br />cOlllJleDSlll1on, gift, g,:"tuity, premium, contribution, or thing of value to a Gambling Control Board employee or <br />member of the Gam6ling control Board. <br />21. I will not recruit a person to become a gambling manager or assistant gambling manager or identify to an organziation a <br />person as a candidate to become a gamliling manager or assistant gamliling manager. a <br /> <br />If any information submitted in the application changes during the term of the license period, the Bingo Hall applicant or licensee ., <br />must notify the board and the appropnate local unit of government under Minnesota Statute 349.213, Subd 2, m writing within ten (10) days <br />of the cbaDge. <br /> <br />e <br /> <br />In addition, I unden;tand, agree and hereby irrevocably consent that suits and actions relating to the sul)iect matter of the Bingo Hall <br />license application, or acts or omissions arising from such application, may be commenced against me m any court of cOlIIJI<etent jurisdiction <br />in Minnesota by service on the Minnesota Secretary of State of any 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 criminal background check or review <br />a1id to share the results with the Minnesota Gambling Control Board. <br />Failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. <br />FURTHER AFFIANT SA YETI:! NOT, except_that this Oath and Consent Statement are submitted in support of the <br />application for a Bingo Hall license from the Minnesota Gambling Control Board. . <br />Subscribed and sworn to ~f~~e this J.J - J/ () <br /> <br />~dayof~~/(AIlJa20 -6fJ2JJ.... ./~~/O~I1U.) <br /> <br />~~ Signature of applicant <br />CoW'P' of <br /> <br /> <br />lYtlrYliQ - b <br /> <br />Notary Public U <br /> <br />My commission expires J - 3/.... 05 IIZI <br /> <br />The infonnation requested on this fonn Wi1l be used by the Gambling C t i.... compliance with Minnesota Statutes and rules <br />governing lawful gambling activities. All of the infonnation that you su fonnation when received by the GCB except <br />if required, your Social Security number, which remains private. <br />Discbure or Social S<eurity Number . <br />You are required to provide your Social Security number on this fonn. Your Social Security number Wi1l be used to detennine your compliance with <br />laws of Minnesota. Authorization for requiring your Social Security number is found at 42 U.S.C. 40S (c)(i). <br /> <br />..;t-I-C)..OOD <br />Date Signed <br />