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LG316 Minnesota Lawful a m b ltng <br /> (10130190) Bingo Persounel A <br /> ATE F AFFIDAVIT of QUALIFICATION <br /> STATE <br /> FOR BINGO HALL LICENSE <br /> COUNT OF AND CONSENT STATEMENT <br /> (Pursuant to Minnesota Statute 349.164) . <br /> r <br /> W <br /> r)'n�• , under oath state that: <br /> (type or print) <br /> t. 1 have not been convicted of a felony. <br /> have never been convicted of a crime involving gambling. <br /> 39 l do not owe delinquent taxes in excess of$500 as defined in Minnesota Statute section 270.72. <br /> 4, 1 am not a licensed distributor or affiliate of a distributor u -.er section 349.161 <br /> 5. 1 am not a licensed manufacturer or affiliate of a manufacturer under section 349.1 63. <br /> 6. 1 am not a wholesale distributor of alcoholic beverages. <br /> ?, 1 will not provide any staff to conduct or assist in the conduct of any lawful gambling on the premises. <br /> 8. 1 will not acquire,provide storage oontrol or inventory control, or report the use of any garnbiing equlpment <br /> used by an organization that conduC.-ts lawful gambling on the premises. <br /> 9, not provide accounting service!� to any organization conducting lawful gambling on the premises. <br /> to. 1 will not solicit,suggest-, encourage or make any expenditures of gross receipts from lawful gambling of <br /> an organization. <br /> tf. 1 will not charge a fee to a person without which the person could not play a bingo game or participate "in <br /> another form of lawful gambling on the premises. <br /> 12. 1 will not provide assistance or participate in the conduct of lawful gambling on the premises. <br /> 13. 1 ill not prepare bingo packets. <br /> In addition, I understand, agree and hereby irrevocably consent that su'ts and actions relating to the subject matter of <br /> the attached bingo hall license application, or acts or omissions ar`,sng from such application, may be commenced- <br /> against me in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any <br /> summons,process or pleading authorized by the laws of Minnesota. <br /> By signature of this document, the undersigned authorizes the Department of Public Safety to co nduct a background <br /> - check or review and to share the results with the Laydul Gambling Conlrol Board. <br /> L ti <br /> Failure to p rovide requiTedinformation or providing false or misleading information may re s ult i n the dental or revocation <br /> of the license. . <br /> FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted i n support of the. <br /> . <br /> ,,• 1bW16ft1A f(0! ff'fi ?.�b%lypr atson from the La"qul Gambling Control Board. <br /> yr ' <br /> WL'05 <br /> da <br /> My-_�• <br /> .,iii• Cinl'll.Expires Jfi$2.1994 <br /> 11111 11111 1 k 1 111 111111111 111111 1 11"1 his h (Signature of applicant-Bingo Hall Personnel) l <br /> r <br /> day of d, 19.13 A, <br /> Marne of Bingo Hall <br /> 0 <br /> -H 0 ;2 6, <br /> 22 1 <br /> Notary Public Bingo Ha!! License Number <br /> My commission expires /071-/i <br />