|
<br />Bingo Hall Personnel Information - LG315
<br />
<br />License number: BH013 Name of person:
<br />
<br />Oath and Consent Statement
<br />
<br />1. I have never been convicted of a
<br />faony.
<br />2. I have never been convicted of a aime
<br />involving gambling.
<br />3. 1 haloe never been convicted of assaul~
<br />a criminal violation involving the use of
<br />a firamn, or making terroristic threats.
<br />4. 1 am not currentiy or ha\ie never been
<br />engaged in or connected with an ilegal
<br />business.
<br />5. I do not owe $500 or more in
<br />delinquent taxES to the state of
<br />Minnesota.
<br />6. I ha\ie not had a sales and use tax
<br />pennit revokro by the commissioner of
<br />revenue within the last two years.
<br />7. I haloe filed, 1tterdemand, tax
<br />returns rl:quired by the commis9oner of
<br />revalue.
<br />8. 1 am not a licensed distributor or
<br />affiliate of a distributor under Minn.
<br />Stat. see. 349.161.
<br />9. I am not a 6censed manufacturer or
<br />affiHate of a manufacbJrff under Minn.
<br />Stat. see. 349.163.
<br />10. I wi' not be an officer, director, paid
<br />employee, or volunteer of a licensed,
<br />exempt, or excluded organization in its
<br />conduct of lawful gambling, or
<br />represent a licensed, exempt, or
<br />exdJded organization in the purchase
<br />of or inft uenee the purchase of lawful
<br />gambling equipment
<br />11. I am not a wholesale distributor or an
<br />affiRate or an empbyee of a wholesale
<br />disbibutor of alcohoic beverages.
<br />12. I wiB not provide any staff to conduct or
<br />assist in the conduct of bingo or any
<br />otherfonn of lawful gambfing on the
<br />premises.
<br />13. 1 wiB not acquire gambling equipment
<br />or pmvK:le inventory control for any
<br />organization that conducts lawful
<br />gambling on the premises.
<br />14. I win not prepare or assist in the
<br />preparation of any reports requ ired by
<br />Minn. Rules, part 7861.0120, subp. 3,
<br />for an organization conducting iawful
<br />gambling on the prem;;es.
<br />15. I win not provide accounting services to
<br />any organization conducting lawful
<br />gambting on the premises..
<br />16. I wiB notsoiidt, suggest, encourage, or
<br />make any expenditures of an
<br />organization's gross receipts from lawful
<br />gambfing.
<br />17. I wil oot marge any fee to a person
<br />without which the person could not play
<br />bingo or partidpate in another form of
<br />I_ful gambling on the pcemises.
<br />18. I wil not provide assistance or
<br />participate in the conduct of lawful
<br />gambfing on the premises.
<br />
<br />Goldie Katherine Siedow
<br />
<br />.
<br />
<br />
<br />19. I wil not permit more than 21 bingo
<br />occasIons I:D be conducted on the
<br />prem ises in any week.
<br />20. I win not reouita person to become a
<br />gambfing mana]er or assistant gambling
<br />manager or identify to an organization a
<br />person as a candidate to become a
<br />gambling man<ger or assistant gambling
<br />manager.
<br />21. 1 wi. not be involved in the procurement
<br />of, or influencing the procurement of,
<br />I_ful gambling equipment for an
<br />organization which conducts lawful
<br />gambling on the li:ensee's premises.
<br />22. 1 wil not pcovide or permit an a'filiate or
<br />person acting on behalf of the bingo haD
<br />licensee to provide any compensation,
<br />gift, gratuity, premium, contribution, or
<br />thing of val ue to a Gambling Control
<br />Soard emplo~ or mffllber of the
<br />Gambling Control Board.
<br />23. 1 wiB not diroctiy or indirectly 9ive gifts,
<br />trips, prizes, loans of money, premiums,
<br />or oth er gratuities to gambling
<br />organizaoons, or their employees, other
<br />than nominal gifts not to exceed a value
<br />of $25 per organizction il a calendar year.
<br />
<br />ri! J2J. i ~ '~ ....so.!i..~ <-}
<br />
<br />(Signature of 0090 naB rsonnel applicall)
<br />
<br />IUrMS~
<br />-Ih
<br />
<br />County of
<br />
<br />before me th is
<br />
<br />Notary Pubic:
<br />My commission expirES:~~~
<br />
<br />In addition, 1 understand, <gree, and hereby
<br />irrevocably consffit that suUs and actions
<br />relating II> the subject matter of the bingo hal
<br />license application, or acts or omissions
<br />arising from such applk:ation, may be
<br />rommenced against me in any court of
<br />compelentjurisdiction in Minnesota by service
<br />on the Minnesota Secretary of State of any
<br />summons, process, or pleading authorized by
<br />the laws of Minnesota.
<br />By signature of this doannent, the underngned
<br />authorizes the Department of Pubic Safety II>
<br />oonduct a background investigation pursuant to
<br />Minnesota Rules, part 7862.0010, subpart lOa.
<br />By signature of this document, the underngned
<br />attests that information provided in th;;
<br />application;; true and oorrect. Failure to
<br />provide requi'ed information, or providing false
<br />or misleading information, may result in the
<br />denial or revocation of the icense.
<br />Changes in application information wll be
<br />submitted w~hin ten days.
<br />
<br />FURTHER AFFIANT SAYElli NOT, except that
<br />th;; Oath and Consent Stitement ;; submitted
<br />in su pport of the application for a bingo hall
<br />license fi'om the Gamblng Control Board.
<br />
<br />.
<br />
<br />JdJ 1.6Lt!1~
<br />Date signed
<br />
<br />SUbsaibed and sworn to
<br />
<br />20 0 tA .
<br />
<br />~l"':-
<br />-......""'""'...
<br />
<br />The information fl!:quested on this form (and any ata:hrrents) ""II be used by the Gcmbling Control Board
<br />(Board) toda:ermine your qualifICations to be invd\'ed in IawfiJlgilTlbling acti'vitles In Minnesota, a1d to assist
<br />the Board in Conducting a bad::ground Investigation of WU, You have a right to refuse to supply the
<br />information requested; however, if you rf'fuse to supply this information, the Board may not be ctIle to
<br />determIne your qualifICations ald, as a consequence, may refuse to register you. If)OO supply the information
<br />requested, the Board will be able to register you. You are required toprowteyour social securityrunber on
<br />this form. Your-sodal security number will be used todttermine your oomp6ance with the talC laws of
<br />Minnesota. Authorllction fOr requiring your soci.. sea..lfity nurJt)er is found at 42 U.S.c. '1)5 (cXi). Yow narre
<br />and address will be public information when received by the Soard, .All the other information that you provide
<br />will be pfivcte data about you until the Board approves your registration. When the Board approvesyour
<br />registration, aN of the information that you have pro~ to the Board In the process rf reJist8"ing wiD become
<br />public EXcept for your social security number-, which remains private. If the Board does rot ~Pf'Q'o'e your
<br />registration, all the information you h~e providEd in the process of registering remains private, with the
<br />exception of your name and address, which will remain public. Privcte data about you are available onPy to the
<br />followilg: Board members, stiff of the Board whose work assignment requires that they h~e acce>s to the
<br />information; the Minnesota Department of PubliC Sahty; the Minnesota Attornev General; the Minnesota
<br />Commissioners of Pdministrction, Finance, and R.evmue; the Minnesota LegislatiVe AOOitor; national and
<br />intemctional gambling regulatory agencies; anyone PUf5Uart to COUlt order; other individuals and agencies that
<br />are specifically authaized by state or federal law to have access to the information; individuals and agencies for
<br />which law or legal ader- authorizes a newusc or sharing of informction ctterthis nd:ice was given; <rid anyone
<br />with your \Witten consent.
<br />
<br />.
<br />
|