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FEB, --04` 00 (FR I ) 12 4 8 IDREFERED �_= E ;L.L��' �?� 8181 <br /> 7M <br /> Tw '* U 61N <br /> Minnesota Lawful Gambling <br /> Organization Officers Affidav"'-_ LG2008 <br /> _ <br /> Affidavit of Qualification of Officers <br /> Stete of -�--�- for an Organization License and <br /> Count of <br /> • Consent Statement <br /> (pursuant to Minnesota statutes <br /> e V �► �� <br /> under oath state that: <br /> 1. 1 have not been, convicted of a feiony. c- � . �y si navjra of this document, the undersigned suthanzes <br /> mfsderineanor within the flue years before the lr=au_���- ±;e epertmant of Public Safety to conduct a criminal <br /> or renewal of the license. background check or review and to share the results with <br /> 2. 1 have never been convicted of a crtma it vn- tie Gamnling Ccntral Eloard. <br /> gambling. F allure to provide required information or providing false or <br /> 3. I have never had a 1isnse issued by the board c information may result in the denial or revocation <br /> permanently revoked for violation of law or board rt:;e. c;the license, <br /> In additlon, I understand, agree, end hereby irrevor :-bey F JRTHEQ AFFIANT SAYETH NOT,except that this Affidavft <br /> consent that suits and a�ans relating to the subject fr.. and Consent Statement are submitted in support Of the <br /> of the organl2a#lon iicense application,or acts or ornis� "PlIcaticn for an arganlzatian license from the Gambling <br /> arising from such application, may be cornnrienced Control Board. <br /> my oroanizatlan and I will accept the ssrvica of prcces' fey <br /> my organization in any court of -=mpetsn; judsdij.-V <br /> Minnesota by service on the Minnesota Secretary <br /> of any summons, process, or pleading aut cruse b` =h- <br /> laws of Minnesata. (kppllcan' Sign Al <br /> f�� I .�� f <br /> Notary Public Information. Applicant�nfornnat�o� <br /> ,,heck the box Indicating your posifi5n: <br /> Notary Public Seal must be current and Conn ct Yh I <br /> seal may =be altered. f,'hief faro;utive Ofcer Treasurer <br /> Subscrlbad and sworn to befcn me this da ax r'tfective Date of officer Change <br /> M �a <br /> Lam- on1e Address <br /> I <br /> 44` e <br /> (Notary Public.Sig ure) <br /> L I <br /> Phone ci <br /> TERRA A r%ate of B;rth ... . . ....��.....( ........ <br /> �A t <br /> .0 Notary Puollc <br /> �.. , Minnesom Nams of-Organization <br /> imp worb j4p ii,at <br /> Elasa License Number <br /> C ussfions 3n this form should be directed to the uca n®ing�actl on <br /> Mail this farm to: n' the Garre,biing Control Board at 651-63 00. This publication <br /> *4 be made available in anemallveformat 0.8, large Dr <br /> int, Braille <br /> upon request Heang imQel r ed indiv,dua16 u si nQ a TTY <br /> may cal <br /> Gambling Control Board To Minnesota Reply Series at f-8ao-627-3620 and ask tc pa ce <br /> Suite 300 south a call to as 1-ens-4oa4. <br /> 1711 Wast County Road 8 Tie lnformatlon requested on this form will Decomee public <br /> Roseville, MN 55113 in-form.atior when received by Me Board,and will be used tc <br /> d,20grmina yaur compllanca witri Minn9eoia statutes end rules <br /> 9civerning iawfui gambling activities. <br /> 0198) <br />