1993_1011_packet - Laserfiche WebLink

Home

LG316 Minnesota awful Gam lin g Bingo H Personnel Affidav't STATE OF f &4 AFFIDAVIT OF QUALIFICATION . . FOR BINGO HALL LICENSE COUNTY of AND CONSENT STATEMENT (Pursuant to Minnesota Statute 349.1 �P ) -�+ .■ � Z0.071 u nd r oath state that:(type or print) • I have not been convicted of a felony. 2. 1 have never been conv'Icted of a crime involving gambling. 3. I& *)t owe delinquent taxes in excess of 500 as defined in Minnesota Statute section 270.7 t 4. 1 am not a licensed distributor or aff iliate of a distributor under section 349.161. 5. l am not a licensed manufacturer or affiliate of a manufacturer under section 349.163. 6. 1 am not a wholesale distributor of alcoholic beverages. 7. 1 will not provide any stafi to conduct or assist in the conduct of any lawful gambling on the premises. 8, 1 will not acquire, provide storage control or inventory control, or report the use of any gambling equipment used by an organization that conducts lawf u gambling on the prernmes, g. 1 will not provide accounting services to any organization conducting lawful gambling on the premises. 10■ 1 will not so-:Y;i,suggest, encourage or make any expenditures of gross receipts from lawful gambling of an organization. 11. l will not charge a fee to a person without which the person,could not play a bingo game or participate in another form of lawful gambling on the premises. 12. i will not provide assistance or parti ;pate in the conduct of lawful gambling on the 'premises. 13. l will not prepare bingo packets. In addition, I understand, agree and hereby irrevocably consent that s u'As and actions relating to the subject matter of the attached bingo hall license application, or acts or omissions arising from such application, may be commenced I against me in a6y court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any sum mo ns,process or pleading authorize d by the lags of M i nngWa■ . By signature of this document, the undersigned authorizes the Department of Public Safety_jo conduct a background cheer or review and to share the results with the Lawful Gambling Control Board. k _Failure to provide req u i,ed information or providing false or misleading information may r e'su It in the den[al or revo6$tion of the license. t ~ u FURTHER AFFIA T SAYETH NOT, excapt that this Affidavit and Consent Statement are submitted in support of the. application for bingo hall license application from the Lawf u 1 Gambling trol Board. l* r ' . 4 ub�scribe�' 1946 Y his (Signature of a Pp lica - in o Hall Personnel Y n K i J?�d ayof A C4 qv toe: Name of B., ,: Hall r Notary Public Bingo Hall License Nuimber My commission expires : .