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<br />., . <br />) <br /> Page 2 of 2 <br /> LG315 Bingo Hall Personnel Information 11/04 <br /> license number (if issued) Name of bingo hall <br /> BH- ~ 13 <br /> Oath and Consent Statement <br /> 1. I have never been convicted of a felony. Of" provide inventory control tor any or person acting on behalf of the <br /> 2.. I have never been convicted of a crime: organization that conducts rawful bingo hall licensee to pruvide any <br /> involving gambling_ gambling on the premises. compensation, gift., gratuity, <br /> J. I have never been convicted of assault, 14. I will not prepare or aSSist in the premium, contribution, or thing of <br /> a oiminal violation involving I:he use of preparation of any reports required by value to a GilmbIing COntrol Board <br /> a fireann, or making terroristic threats. Minnesota Rules 7861.0120, SUbp. 3, employee or member of the Gambling <br /> 4. I am not OJITentJy or have never been for an organization ronducting lawful Control Board. <br /> engaged in Or connected with an illegal gambling on the premises. 23, I \Nill not directly or indirectly give <br /> business. 15_ I will not provide aC(x)iXlting services to gifts, trips, prizes, loans of money. <br /> 5. I do not owe $500 or more in any organization conducting lawful . premiums, or other gratuities to <br /> delinquent taxes to the state of gaffibling on the ~jses. gambling organizations, or their <br /> Minnesota. 16. I will not solicit, suggest,. encourage, or emplOyeeS, other than nominal gifts <br /> 6- I have not had a sales and use tax make any expenditures of an not to exceed a value of $25 per <br /> permit re.rok:ed by the commissioner of organization's gross receipts from lawful organization in a calendar year. <br /> revenue within the last two years. gambling. In addition, 1 understand, agree, and <br /> 7. I have filed, after desnand, tax returns 17_ I win not charge any fee to a person hereby irrevocably consent that suits and <br /> required by the. commissioner of wittlout which the person could not actions relating to the subject matter of <br /> revenue. play bingo or partidpate in another the bingo hall license application, or acts <br /> 8. I am not a licensed distributor or form of lawful gambling on the Of omissions arising from such <br /> affiliate of a distnbutor under Minnesota premises. application, may be oommenced against: <br /> staWte 349.16l. lB. I wiD not provide assistance or me in any court of competent jurisdiction <br /> 9. I am not a licensed manufacturer or partidpat:e in the conduct of lawful in Minnesota by service on the Minnesota <br /> affiliate of a manufacturer under gambling on the premises. Secretary of State of any sununons, <br /> M;_ StatlJte 349.163. 19. I win not permit more than 21 bingo process, Or pleading authorized by the <br /> 10.1 witt not be an officer, director, paid occasions to be conducted on the laws of Minnesota. <br /> emptoyee, or volunteer of any premises In any week. By signature of this document, the <br />0 organization in its ronduct of lawful 20. I will not recruit a person to become a <br /> gambling, or represent an organization gambling manager or assistant undersigned authorizes the Department . <br /> in the purchase of, or influence the gambling manager or identify to an of Public Safety to (Ollduct: a backgroo.nd <br /> purchase of, lawfl.B gambling organization a person as a candidate to investigation pursuant to Minnesota <br /> equipment. become a gambling manager or Rules 7862.0010, Subpart lOa. <br /> 11.1 am not a wholesale distributor Or an assistant gamb~ng manager. Failure to provide required information or <br /> affiliate 01' an employee of a wtdesale 21. I will not be involved in the providing false or misleading information <br /> distributor of alcoholic beverages. proaJrement of, or influencing the may resutt. in ttle denial or revocation of <br /> 12. I wm not provide any staff to conduct procurement of, lawful gambling the lil:ellSe. Olanges in application <br /> or assist: in the conduct of bingo or any equipment fur an organization whidl information will be submitted in writing <br /> other form of lawful gambling on the conducts lawful gambling on the no later than 10 days after the change <br /> "..em;ses. licensee's premises. has t~ effect. <br /> 13. I will not acquire gambling equipment 22.1 wl1l not provide or permit: an affiliate <br /> <br /> <br /> <br />!J t/./J.h ~. K J?: f pkn-' <br />SignatlXe of bingo heR person applICant <br /> <br />-..L.J.dLJ (.) L) <br />Date <br /> <br />Attach and Mail <br /> <br />Attad1 all LG315 forms to ltJe LG300 ~ Bingo Hall Ucense <br />Application fonn, or submit when inf'orrnation changes. <br />and send to: <br /> <br />Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville. MN 55113 <br /> <br />Tl\einfOl'TT'lationrequestedonthisfam(and any of Minnesota. Authorization for requiring your <br />attachments} will be used by the Gambling Social Security number is found at 42 U.S.C. <br />Control Board (Board) to determine your 405(c)(i).Yournameandaddresswillbepublic <br />qualifications to be in....oIved in lawful gambling information when received by the Board. All <br />C'CtiVities in Minnesota. and to assist the Board otherinfmmation 1hatyou prov'de win be private <br />inronducling a background investigation of you. data aboLrt)'Oll until the Board approves your <br />You have the right to refuse to supply the registration. When the Board approves yOllr <br />inforrnationrequested;however.ifyourefuselO registration. all informatlon that you have <br />supply this information, the Board may not be pro....ided to the Board in the process of <br />able to determine your qualifications and, as a registering wal become public ex(;ept for your <br />consequence. may refuseto registetyou. If you social sea.nity number, which remains privale_ <br />suppfytheinforrnation requested. the Boardwill If the Board does not approve yolJr registration, <br />be- able 10 register you. You are required to all information provided ill the process of <br />provide your Social Security number on this registering remains private. with the exception <br />fonn YOlR"Sociat Security nomberwill be used of your name and <KldTess which will remain <br />to detennine yow-compliance with the tax laws public. Private data about you is available only <br /> <br />to the foUawing: Board memben>. Board staff <br />whose work assignment requires th<rt they ha~ <br />access to the information: lhe Department of <br />Public Safely: the Attorney General; the <br />Commissioners ofAdministr.ation. Finance, and <br />Revenue; the Legislative Auclilor; ntltional and <br />international gambling regulatory agencies; <br />anyone pursuant to (;Our!: Ofder; other individuals <br />and agencies lhatmay be speciflc:<J"Y authorized <br />by state or federal law to have access to such <br />information; indlviduals and agencies for which <br />law or legal order authorizes a new use orsharing <br />of the information after this notice is given: yoll; <br />and anyone with your written ccnsent This form <br />will be made available in altematille format (i.e. <br />large print, Braille) upon request. <br /> <br />. <br /> <br />) <br /> <br />9-d <br /> <br />0l>BI-EBl.-E9l. <br /> <br />mopa~s <br /> <br />p~"e-a <br /> <br />dl.5:~1 50 10 q".oI <br />