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l--. Gambling Manager Requirements:-- . 1. An a~~ual g~mbling manager license fee of $100 is required. Gambling Manager Authorization Current License Term 4/1/2004 - BOOrd- use- o;,jy ': GM-01485-001 to 3/31/2006 . Elizabeth Louise Matson 2774 Dellwood Ave, Roseville, MN 55113 (651)633-0156 Bond: Old Republic Surety Co RPS 579134 Last Education: 11/19/2004 Check this box if the person listed a bove will not be Note: A new person may not renewing as gambling manager. Enclose a separate " assume or act as gambling LG212 application for the new applicant. Effective / manager until licensed by the date will run concurrent with the organization's license. Gambling Control Board. 1M e:=J Gambling Manager Affidavit and Consent Statement 1. I have never been convicted of a felony or a crime involving gambling. 2. I have never committed a violation of law or Board rule that resulted in the revocation of a license issued by the Board within five years before the date of the license application. 3. I have never been convicted of a criminal violation involving fraud, theft, tax evasion, misrepresentation, or gambling. 4. I have never been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii) making terroristic threats. 5. I have never been, or am I now, connected with or engaged in an illegal business. 6. I have never had a sales and use tax permit revoked by the commissioner of revenue within the past two years. 7. I have never, after demand, failed to file tax returns required by the commissioner of revenue. S. I do not owe $500 or more in delinquent taxes as defined in section 270.72. 9. I have been an active member of the organization for at least two years at the time of our organization's initial license application, or have been an active member for at least the most recent six months prior to the effective date of our organization's license renewal. 10. I am not a gambling manager or an assistant gambling manager for another organization. 11. I am not a lessor, a member of the lessor's immediate family or a person residing in the same household as the lessor, or an employee of a lessor of a premises where this organization has a permit issued from the Board to conduct lawful gambling. 12. I am not involved directly or indirectiy as a bingo hall owner, manufacturer, or distributor. 13. I am not the chief executive officer of this organization. 14. I am not the treasurer of this organization. 15. I was not an officer of an organization at a time when an offense occurred which caused that organization's license to be revoked. Background Check. By signature of this document, the undersigned authorizes the Departments of Public Safety and Revenue to conduct a criminal and tax background check or review and to share the results with the Gambling Control Board. Further, I understand, agree, and hereby irrevocably consent that suits and actions relating to the subject matter of this gambling manager license application, or acts or omissions arising from such application, may be commenced against me.or my organization and I will accept the service of process 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. Failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. Changes in the information submitted in this application will be submitted in writing no later than 10 days after the change has taken effect. . .