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<br />Minnesota Lawful Gambling 7/07 <br /> <br />LG200B Organization Officers Affidavit . <br />Affidavit of Qualification of Officers for an Organization Ucense and Consent Statement pursuant to Mlnneso~ statutes <br /> <br /> <br />Organizalionname c., 'J... ) F. I.J/),dcd-I ~ '" License number 0 If;;;J.4 I <br /> <br />Businessaddres~X"~ nf,J B(\'~~_Cily/ZiPCode h'ln $ / I ~ <br />(may not be the address oflhe gambling manager, trea ufer, accountant, or leased s.le address) <br /> <br /> <br />Check the position: X_Chief executive officer <br /> <br />Effective date of officer change E_-,_L2-'-J2J!__ <br /> <br />Officer's first name <br />@lVr", Ie!. <br /> <br />I Middle name <br />Lo..~~o:.:(,.. <br /> <br />Treasurer <br /> <br />last name <br />{l'/l\c.C.o..uk'1 <br /> <br />A--.re <br /> <br />Maiden or previous name <br /> <br />(qa.s .:re-~rqM <br /> <br />City A-rd e.-. IL II s <br />f <br />Socialsecurilynumber -'!]k- -_ /{L- 9!jjL Dateofbirth_ <br />t.H- 3H5 <br /> <br />Home address <br /> <br />Officer's daytime phone number --b151 .- <br /> <br />State rn rJ Zip code S 5 II Z- <br /> <br />1J--/23-3h <br /> <br /> <br />I affirm that the infonnation stated above is accurate <br />and lhat <br />I have never been convicted of a felony or gross <br />misdemeanor involving theft or fraud. <br />J have never been convicted of a crime- involving <br />gambling. <br />I have never had a license issued by the -board or <br />director permanently revoked for violation of law or <br />board rule. <br /> <br />In addition, I understand, agree, and hereby irrevocably <br />consent that suits and actions relating to the subject <br />matter of the organization license application, or acts <br />or omissions arising from such application, may be <br />commenced against my organization and I will accept <br />the service of process for my organization in any court <br />of competent jurisdiction in Minnesota by servke on <br />the Minnesota Secretary of State of any summons, <br /> <br /> <br />Signature,~ e:L __dY7c.. Q <br /> <br />Fax to 651-639-4032 <br />or mail to: <br />Gambling Control Board <br />1711 W County Road B, #300 South <br />Roseville, MN 55113 <br /> <br />process, or pleading. authorized by Minnesota laws. <br />By signature of this document the undersigned <br />authorizes the Department of Public Safety to conduct a <br />criminal background check or review and to share the <br />results with the Gambling Control Board. <br /> <br />Failure to provide required infonnation or providing false <br />or misleading information may result in the denial or <br />revocation of the license. <br /> <br />If this form is being submitted for a change in the chief <br />executive officer, the chief executive officer also affirms <br />that I am the chief executive officer of the organization; <br />I assume full responsibility for Ihe fair and lawful <br />operation of all activities to be conducted; and I will <br />familiarize myself with Minnesota laws governing _lawful <br />gambling and rules of the Board, and agree to abide by <br />those laws and rules, including amendments to them. <br /> <br />Date 5: -f 2- - 08 <br /> <br />QUQstions: Call the Ucenslng Section of the Gambling Control Board al651-639-4000. <br />This form will be made available in alternative format {i.e. large print. Brame) Upon request <br />The information requested on this fann. with the exception of your social security number, <br />will become public information when received by the Board. and wilJ be used to detennine <br />your compliance With Minnesota statutes and rules governing lawful gambling activities. <br />