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<br />Bingo Hall Personnel Information - LG315
<br />
<br />. License number: BH013 Name of person:
<br />
<br />Oath and Consent Statement
<br />I have never been convicted of a felony.
<br />I have never been convicted of a crime
<br />involving gambling.
<br />3. I have never been convicted of assault} a
<br />criminal violation involving the use of a
<br />firearm, or making terroristic threats.
<br />4. I am not O1rrently or have never
<br />been engaged in or connected with an
<br />illegal business.
<br />5. I do not owe $500 or more in delinquent
<br />taxes to the state of Minnesota.
<br />6. I have not had a sales and use tax permit
<br />revoked by the commissioner of revenue
<br />within the last two years.
<br />7. I have filed, after demand, tax returns
<br />required by the commissioner of revenue.
<br />8. I am not a licensed distriburor or affiliate
<br />of a distributor under Minn. Stat sec.
<br />349.161.
<br />9. I am not a licensed manufacturer or
<br />affiliate of a manufacturer under Minn.
<br />Stat sec. 349.163.
<br />10. I will not be an officer, director, paid
<br />employee, or volu nteef of a licensed,
<br />exempt, or excluded organization in its
<br />conduct of lawful gambling, or represent
<br />. licensed, exempt or exduded
<br />rganization in the purchase of or
<br />influence the pun:hase of lawful gambling
<br />equ ipment
<br />11. I am not a wholesale distriburor or an
<br />affiliate or an employee of a wholesale
<br />distributor of alcoholic beverages.
<br />12. I will not provide any staff ro conduct or
<br />assist in the conduct of bingo or any
<br />other form of lawful gambling on the
<br />premises.
<br />13. I will not acquire gambling equipment or
<br />provide inventory control for any
<br />organization that conducts lawful
<br />gambling on the premises.
<br />14. I will not prepare or assist in the
<br />preparation of any reports required by
<br />Minn. Rules, part 7861.0120, subp. 3, for
<br />an organization conducting lawful
<br />gambling on the premises.
<br />15. I will not provide accounting services to
<br />any organization conducting lawful
<br />gambling on the premises.
<br />16. I will not solidt, suggest, encourage, or
<br />make any expenditu res of an
<br />organization's gross receipts from lawful
<br />9ambling.
<br />17. I will not charge any fee to a person
<br />without which the person could not play
<br />bingo or partidpate in another form of
<br />_awful gambling on the premises.
<br />I will not provide assistance or participate
<br />in the conduct of lawful gambling on the
<br />premises.
<br />
<br />1.
<br />2.
<br />
<br />Goldie Katherine Siedow
<br />
<br />
<br />19. I will not permit more than 21 bingo
<br />occasions to be conducted on the premises
<br />in any week.
<br />I will not recruit a person to become a
<br />gambling manager or assistant gambling
<br />manager or identify to an organization a
<br />person as a candidate to become a
<br />gambling manager or assistant gambling
<br />manager.
<br />I will not be involved in the proaJrement of,
<br />or influendng the procurement of, lawful
<br />gambling equipment for an organization
<br />which conducts lawful gambling on the
<br />licensee's premises.
<br />I will not provide or permit an affiliate or
<br />person acting on behalf of the bingo hall
<br />licensee to provide any compensation, gift,
<br />gratuity, premium, contribution, or thing of
<br />value to a Gambling Control Board employee
<br />or member of the Gambling Control Board.
<br />I will not directly or indirectly 9ive 9ifts,
<br />trips, prizes, loans of money, premiums, or
<br />other gratuities to gambling organizations,
<br />or their employees, other than nominal gifts
<br />not to exceed a value of $25 per
<br />organization in a calendar year.
<br />
<br />20.
<br />
<br />21.
<br />
<br />22.
<br />
<br />23.
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<br />r/1-Dlt ~ K rd~ p :o~
<br />
<br />(Signature of bingo hall personnel applicant)
<br />
<br />County of 1\().YY\~e,/
<br />
<br />before me this
<br />
<br />In addition, I understand, agree, and hereby
<br />irrevocably consent that suits and actions
<br />relating to the subject matter of the bingo hall
<br />license application, or acts or omissions
<br />arising from such application, may be commenced
<br />against me in any court of competent jurisdiction
<br />in Minnesota by service o"n the Minnesota
<br />Secretary of State of any summons, process, or
<br />pleading authorized by the laws of Minnesota.
<br />By signature of this document, the
<br />undersigned authorizes the Department of Public
<br />Safety ro conduct a background investigation
<br />pursuant ro Minnesota Rules, part 7862.0010,
<br />subpart lOa.
<br />By signature of this document, the
<br />undersigned attests that information provided in
<br />past applications is true and correct. Failure to
<br />provide required information, or providing false or
<br />misleading infonnation, may result in the denial or
<br />revocation of the license.
<br />Changes in application information will be
<br />submitted within ten days.
<br />
<br />FURTHER AFFIANT 5AYETH NOT, except that this
<br />Oath and Consent Statement is submitted in
<br />support of the application for a bingo hall license
<br />from the Gambiing Control Board.
<br />
<br />~/51~
<br />Date sig ned
<br />
<br />Subscribed and sworn to
<br />
<br />The information requested on this form (and any attadlrrents) will be used by the Gambling Control Board
<br />(Board) to determine 'yOur qualifications to be involved in lawful gamtAing activities in Minnesota, and to assist
<br />the Board in conducting a background investigation of you. You have a right to refuse to supply the information
<br />requested; however, If you refuse to supply this information, the Board may not be able to determine your
<br />qualifications and, as a consequence, may refuse to register you. If you supply the information requested, the
<br />Board will be able to register you. You are required to prov1de your social security number on this form. Your
<br />social security number wit be used to determine your compliance v.rith the tax laws of Mnnesota. Authorization
<br />for requiring your social security number is found at 42 U.S.c. 405 (c)(i). Your name and address will be public
<br />information when received by the Board. Ail the other information that you provide wdl be private data about
<br />you until the Board approves your registration. When the Board approves your reglstratlon, all of the information
<br />that you have provided to the Board in the process of registering will become public except for your sodal
<br />seCUrity number, which remains private, If the B:>ard does not approve your registration, all the information you
<br />have provided in the process of registering remains private, with the exception of your name and address, which
<br />will remain public. Private data about you are avaiiable only to the following: Board members, staff of the Board
<br />whose work assignment requires that they have access to the infonnation; the Minnesota Department of PubHc
<br />Safety; the Minnesota Attomey General; the Minnesota Commissioners of Administration, Finance, and Revenue;
<br />the Mnnesota Legislative Auditor; national and intemational gambling regulatory agencies; anyone pursuant to
<br />court order; other Individuals and agendes that are specifically authorized by state or federal law to have access
<br />to the information; individuals and agencies For which law or legal order authorizes a new use or sharing of
<br />information after this notice was given; and an'yOl1e with your written consent
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