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LG3 ti <br /> 6 Minnesota LawJ911 Gambting <br /> Blingo H Personnel Affidavit <br /> � VALIFIATIO�!LaQ�STATE�F <br /> AFFIDAVIT OF <br /> ® @, )' S'S. FOR BINGO}BALL LICENSE <br /> AND CONSENT STATEMENT <br /> C�I�hIT �F . <br /> • (Pursuant to Minnesota Statute 349.164) <br /> • , under oath state that: <br /> (type or print) <br /> 11 L have not been convicted of a felony. <br /> 2. 1 have never been convicted of a prime involving gambling. <br /> 3. l do not owe <br /> delinquent taxes in excess of$boo as defined in Minnesota Statute section 270.720 <br /> 4. am not a licensed distributor or aff iliate of a distributor under section 349.161. <br /> 5. <br /> l 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, l will not provide an y staff to conduct or assist in the conduct of any 1 awl ul gambling on the premises. <br /> ' `re provide storage control or inventory control,or report'the use of any gambling equipment <br /> �, l wall not acquire,� � s lawfu!gambling on the premises. <br /> used by an organization that conduct g <br /> 9. l will not provide accounting services to any organization conducting lawful gambling on the premises* <br /> � e � <br /> 10, tw`ll not soli` ,su gga s14 encourage or make any expendhu re s of gross receipts from lawf ui gambling of <br /> an organization. <br /> • e person could not lay a bingo game or participate <br /> 11. 1 will not charge a fee to a person rthout which th p R <br /> another form of iawful gambling on the p?-c- <br /> 12. y es. : <br /> • o artici a, the conduct of lawful gambling on the premises. <br /> l will not provide assistance r p p <br /> 13. l will not prepare,bingo packets. <br /> 1 <br /> N <br /> iti irrevocably�onsenl that subs and actions&-slating to the subject ratter of <br /> In e,dd���an, 1 understand, agree and hereby trre�oc � � i c application, may�e corr�r�e�oe� <br /> the anached bingo hall license application, or acts or omissions arising from such , y <br /> g <br /> • com tent j urisdiction in Minnasota by sarvice on the Minnesota Secretary of State of any <br /> agatinst me in ar�y�u�of <br /> summons process or pleading authorized by the Laws of Minnesota. , <br /> • the ndersi reed authorizes the Department❑f Public Sala �o conduct a background <br /> By signature of this document, 9 <br /> held or review and to share the results with the Lawful ambling Control hoard. • <br /> F ' formation may result in the denial or revocation <br /> Failure to provide required information or providing false or misleading i n Y <br /> of the license. <br /> FURTHER AFF1 ANT SAYETy� - <br /> . , ���, except that this Affidavit and Consent Statement are submted in support of# e <br /> %p i i o alb, i e :se"ap ic ation from the Lawful Gambling Control Board. <br /> ���� A •41 <br /> r <br /> ��m. • �� 1 a ils (Signature of applicant-B' p Hall personnel) <br /> r <br /> day of 1 g Marne of BinZe,LrC- 1F <br /> go Halt <br /> * r <br /> Notary Public Bingo Hall Licenseun�ber IN <br /> ry <br /> •it <br /> My Commission expires �-r <br />