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L 316 MirLrLesota wfu l Carte l ing <br /> (10f3080) Bingo H Personnel Affidavit <br /> STATE OF t�. T04- AFFIDAVIT OF QUALIFICATION <br /> S.S.i r7 FOR BINGO HALL LICENSE <br /> COUNTY OF AND CONSENT STATEMENT <br /> (Pursuant to Minnesota Statute 349.164) <br /> I � &dF w �T''''f'+ under oath state that: <br /> (type or print) <br /> 1. have not been convicted of a felony. <br /> 2. 1 have nearer been convicted of a crime involving gambling. <br /> 3. 1 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 under section 349-161. <br /> 5. 1 am not a licensed-manufacturer or affiliate of a manufacturer under section 349.163. <br /> 6. 1 am not a wholesale distributor of alcoholic beverages. <br /> 7. 1 will not provide any staff to conduct or assist in the conduct of any lawful gambling on the premises. <br /> m <br /> 3. 1 �will not acquire,p g 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 /> 9. 1 will not provide accounting services to any organization conducting lawful gambling on the premises. <br /> 10. 1 will not solicit,suggest, encourage or make any expend ores of gross receipts from lawful g arnbii n g of <br /> an organization. <br /> 11. 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 will not prepare bingo packets. <br /> In addition I understand, agree and hereby irrevocably consent that subs and actions Waiting to the subject matter of <br /> the attached bingo hall license application, or acts or omissions arising from such application, may be commenced <br /> against me in an oourt of competent jurisdiction in Minnesota by service on the Minnesota secretary of state of any <br /> g Y . <br /> summons,process or pleading authorised by the laws of Minnesota. - <br /> • or'Zes tha Depart of Public Saf a to conduct a background <br /> w �y signature of this dac�rrnerlt,#}�e undersigned auth � i p .. <br /> ch or review and to share the results with the Lawful Gambling Control Board. <br /> o id a r uired inf orrnation o r rovidin f als a or misleading i ref o rmation m ay re's ult i n th a d en gal o r revocation <br /> .FallUre 10 pr v � p g <br /> of the license. ' <br /> w <br /> 1 NT AYETH NOT except that this Affidavit and Consent Statement are sui m'r�ed in support of the r <br /> FURTHER A�F A � p <br /> application for bingo hall license application from the Lawful Gambling Control Board. <br /> Subscribed and sworn to before me this a (Signature of applicant- Bingp Hall personnel) <br /> � 6Zktqlat- 19 Name of Bingo H al l C-0 L.�t-j a-L-Lep LAAt.- <br /> Notary Public r s u <br /> 3-c29- JANE E PAU LSO ley co m rn Isslor'1 exp r es L} "OTAIIv 111111c-.AAINNESoTA <br /> WASHINGTON COUNTY <br /> +. ... My cownissiort expires 3.29+98 <br /> -�_�- - - - - W � �. - <br />