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i E B i U i' V 1 i r l r E i 1 L i ✓ i� 1 + ' 1�AMP <br /> JJ v <br /> Minnesota Lawful Gambling <br /> Organization Officers Affidavit LG20N3 <br /> State of I tJ-,j <br /> Affidavit of Qualification of Officers <br /> r-,��,}� <br /> -�-- for an Organization License and <br /> Consent Statement <br /> Count of <br /> Y a W S a," �---�- (p ursuant to Minnesota statutes <br /> 1, rAALJJ� .Tl&�ClAlhlK <br /> ,�, Qndar oath state that: <br /> 1. 1 have not been convicted of a felony cry i:;y si nature of this document, the undersigned authorizes <br /> misdemeanor w1thin the five years befora the 1=S I � De artment of Public Safety to conduct a criminal <br /> or renewal of the license. '�d p y <br /> .ackgrnt;nd check or review and to share the results with <br /> 2. nave never been convicted of a crime lr`ia vir, 'ie Gem Ling Control Board. <br /> gambling, Failure tc provide required information or providing false or <br /> 3. f have never had a license issued by the board a!df,f,%�-r rnisleadin9 information may result in the denial or revocation <br /> permanently ravoked.for violation of law or boas _e. f the license. <br /> In addition, I understand, agree, and hereby lrravcCat . x"URT#ERAFFIANT SAYE H RIOT,except that this Affidavit <br /> consent that salts and actions relating to the s b e: r -ind Cansent Statement are submitted in support of the <br /> of the organization licenas jappllcatian,or acts or on3 i�pplieatl,---,n for an organization ilcstlse from the Gambling <br /> arising from such application, may be commenced q; t (;ontrol Eaud. <br /> my organization and [will accept the service of prciz�e4 '2,r <br /> my organization in any court of corn etent juriso.cti-,� <br /> Minnesota by service on the ltdinnes is Secretary -if -triF� � <br /> of any summons, process, or pleading authafxe b- t <br /> laws of Minnesota. � ppll rt Signature) <br /> Notary Public Information. !Applicantlnformation <br /> :hack the box indlcating Your.position: <br /> lary <br /> No' Pub lic Sea! must be current and ccrr�ct- l�ti <br /> seal may rcpt be altered. Chief executive Of er_ Treasurer Q <br /> s d sworn to before me this C-,�y��T ;!-.ffac 1VFg Data Of O'�Cer Chang® , ca�� <br /> Sub cl��e an ,. <br /> Horne address 2e)v <br /> %ity 'It � <br /> s to tefizi p /L•r r r-11 3-- <br /> (Ncrary Rude 511170 tu <br /> i None <br /> V, <br /> Min neGeaU�A <br /> VA <br /> TERRY <br /> ................. <br /> Cate of f i rth Notary Public <br /> MY Cam RI MBI n EXPITIM JIM.31. <br /> Name of Jr anizatlon <br /> Sage Llconse Number <br /> 1uegtlan6 on this form should be directed to the Ucensing Section <br /> J the Ga,11allpIg Control Board at 8511-631 000. This PUMIC8110n <br /> Mail this form tc: will be misde available in aftemative format i.e. iorge print,Braille <br /> upon request.Hearing impaired individua16 using a 77Y may ca!, <br /> Gambling Control Board 'fie Minnesota ReiaV Service at 1-80M27-3529 and ask to place <br /> Suite 300 South �call to 651439W4001 . <br /> 1717 West Counry Read 9 7h@ ink[mation raqueated an this farm will becornbe public <br /> Roseville, MN 55113 nformatlon when received by the Board, and will be used 'to <br /> determine your CaMp#ianee with Minnseata statutes and rules <br /> Aavernft lawfui gambling act titles. <br /> �g198� <br />