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1993_1011_packet
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1993_1011_packet
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10/13/2011 10:17:47 AM
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LG316 Minnesota Lawful Gam-bling <br /> (10130/90) Bingo Hall Personnel Affidavit <br /> STATE OF W LIV Al t-':4 e r'e4 AFFIDAVIT OF QUALIFICATION <br /> Jy <br /> S.S. FOR BINGO FALL LlCENBE <br /> COUNTY OF AND CONSENT STATEMENT <br /> (Pursuant to Minnesota Statute 349.1 64) <br /> 1 5 Im mc Al-,S under oath state that. <br /> (type or print) . <br /> 11 1 have not been convicted of a felony,, <br /> have nearer been convicted of a crime involving gambling. <br /> 3. 1 do not owe delinquent taxes in excess*: $500 as defined in Minnesota Statute section 270.72. <br /> 4. 1 am not a licensed distributor or affiliate of a distributor under section 349.161. <br /> . I am not a licensed manufacturer or affiliate of a manufacturer under section 349.1163. <br /> 6. l am not a ri+-!esale distributor of alcoholic beverages. <br /> 7■ 1 will not provide any staff#o conduct or assist in the conduct of any lawiul gambling on the premises. <br /> I will not acquire, provide storage control or inventory control,or report the use of any gambling equipment <br /> used by an organization that conducts lawful gambling on'the premises. <br /> g, 1 will not provide accounting services to any organization conducting lawful gambling on the premises. <br /> 10. will not solicit,suggest, encourage or make any expenditures of gross receipts from lawful gambling of <br /> an organization. <br /> 11■ 1 will not charge a fee to a erson without which the person could not play a bingo game or participate in <br /> another form of lawful gam ling on the premises. <br /> 12. 1 will not provide assistance or participate in the conduct of lawful gambling ors the premises. <br /> 13. l will not prepare bingo packets. <br /> In addition,, I understand, agree and-hereby irrevocably consent that sins and actions relating to the subject matter of <br /> th a attach e bi ng a hall lice ns a application,.or acts or o mis slo ns arising f ro m such appl ication, may be co m m anced <br /> against m e i n ariyr court of competent jurisdiction in l in n e sot a by service on the Minnesota Secretary of tats of any <br /> summons,process or pleading authorised by the lags of Minnesota. <br /> By signature nature of this document,the undersigned authorizes the Department of Public afety'lo 00nduct a background <br /> chi or review and to share the results with the Lawful Gambling Control Board. <br /> M <br /> Failure to provide required information or providing ials e or misleading lnform Wdo n may re's u It in the denial o r revocatyor <br /> of the license. <br /> FURTHER AFFIANT BAYETH NOT, except that this Affidavit and Consent Statement are submitted in support of the. <br /> a licat io r�for r b in o hall license application from the Lawful Gambling Control Board. <br /> WMkW � ±�� VAMM�k�,-W <br /> ph <br /> l �i !N 5 t •� � i F ■ ■ 1 <br /> ibscribeAW�s r t of e is �i atu re of apply' nt- gp Hall Personnel) <br /> • lFe.) Zr-VI'Fm A. A E <br /> /9;LA.dayof.j( UA4jt: 'f g <br /> Name of Bingo Hall <br /> 14, - r <br /> Notary Public Bingo ball License Number W <br /> My commission expires <br />
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