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LG316 Minnesota Lawful Gard tin.9 <br /> (10130190) f l*dav*t <br /> Bingo H Personnel Af <br /> TAT <br /> F r ;-5 AFFIDAVIT OF QUALIFICATION <br /> � S.S. <br /> FOR BINGO HALL LICENSE <br /> COUNT <br /> F = ' ^ AND CONSENT STATEMENT <br /> (Pursuant to Minnesota Statute 349.164) �F <br /> } ter # under oath state that. <br /> t <br /> (type or print) . <br /> l have not been convicted of a felony. <br /> 2.1t,•.,�� I have never been convicted of a crim ;nvalving gambling. <br /> 3. • I do not owe delinquent t axes in excess of$500 as defined in Minnesota 1-tatute section 270.720, <br /> 4. 1 am not a licensed distributor or affiliate of a distributor under section 34gt1 61. <br /> 5. •` I am not a licensed manufacturer or affiliate of a manufacturer unde r section 349.16 . <br /> G. 1 am not a wholesale distributor of alcoholic beverages. <br /> , <br /> 7. C I will riot Provide any staff to conduct or assist in the conduct of any lawful gambling on the premises. <br /> th a use of any garbling equipment <br /> S. I will not acquire, g , <br /> ion that conducts lawful gambling on the premises. <br /> used by an orgar,i�at 9 � <br /> g. l will not P rovide accounting services to any organization conducting lawful gambling on the premises. <br /> 10. r 1 will not solicit,suggest, encourage or make any expondAures of gross receipts from lawful gambling of <br /> an organization. <br /> ou which the eson could not la a bingo garna or participate in <br /> 11. f4 1 will not charg e a f e e to a e rson whh t w p p W <br /> another form of lawful gambling on the premises. <br /> 12. yk i <br /> W} I will not PrOvide assistance or participate in the conduct of lawful gambling on the premises. } <br /> s <br /> 13. i+O I will not prepare bingo packets., <br /> a irrevocably consent that suits and actions relating to the subject matter Pf <br /> In addttton, l understand, agree and hereby � <br /> the attached bingo hall license application,lication,or acis or omissions arising from such application, may be commenced�. <br /> h g pp <br /> a atnst me in afiy court of competent jurisdiction in Minnesota by serve on the Minnesota Secrelary of State of any <br /> summons,process or pleading authorized by the laws of Minnesota. , <br /> s , <br /> sl natura of this document,the undersigned authorizes tha Departrnant of Public Safety to conduct a background <br /> By g Gambling <br /> n control Board. <br /> check or review and to share the results with the Lawlu I g <br /> . L <br /> Faure to provide required information or pror,,d.ng false or m isleadin information may result in the dental o r revocaton <br /> of the license. <br /> FURTHER AFF1 ANT SAY ETH NOT, except that this Affidavit and Consent Statement are submitted in support of the. <br /> t <br /> application for bingo hall license application from the Lawful Gambling Control Board. <br /> Subscribed and sworn <br /> to before me this (Signature of applicant-Eingp ball Personnel) <br /> /991 dad of 99!. . . <br /> Name of Bing o Hall <br /> * <br /> Amr <br /> f - No Bingo ball License Number ## <br /> ' tai T. OWENS }.. <br /> T C--r� M A . <br /> y commissib' s <br /> r V F <br /> key CO I rs ION EXPIRES 1 <br />