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