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LG316 xt'hnesota Lawful Garabling <br /> (10130190) Blingo Hall Personnel A <br /> STATE OF AFFIDAVIT OF QUALIFICATION <br /> S.S. FOR BINGO HALL LI EN <br /> COUNTY OF e* F k AND CONSENT STATEMENT <br /> (Pursuant to Minnesota Statute 349.164) <br /> ,� , under oath state that: . <br /> (type or print) . <br /> 1 f have not been convicted of a felony,, <br /> 2. I have nearer been convicted of a crime invoi,;..:`:g gambling. <br /> 3. l do not owe delinquent taxes in excess of Zz.ti "'J as defined in Minnesota Statute section 270.7 2,, <br /> 4. 1 am not a licensed distributor or affiliate of a ;: :.;butor under section 349.161. <br /> S, 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 /> 7. 1 will not provide any staff to conduct or assist in the conduct of any lawful gambling on the premises. <br /> • 3. 1 will not acquire, provide s#orage 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 /> g. 1 will not provide accounting services to any organization conducting lawful gambling on the premises. <br /> 10. 1 will not sollc'ft,suggest, encourage or make any expenditures of gross receipts.f ro rn lawful gambling of <br /> an organization. <br /> 11. 1 will not charge a fee to a erson whhout which the person could not playa bingo game or participate in <br /> another form of lawful gam ling 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 /> io 1 understand agree and here irrevocably consent that suits and actions relating to the subject matter of <br /> In addition, � g by Y <br /> the anached bingo hall license application, or acts or omissions arising from such application, may be commenced <br /> against me in ariy court of oompatent jurisdiction ire Minnesota by service on the ?Minnesota Secretary of State of any <br /> summons,process or pleading authorized by the laws of Minnesota. ' <br /> By s"g nature of this docurnent tha u nd e rs ig n e d authorizes the Department of Public S of eta jo conduct a background <br /> pheck or review and to share the results with the Lawful Gambling Control'Board. <br /> Failure to p roved e requ ired inf ormation o r prov id in g f als a or m is le ading i of o rrnation may result in tha d e n Lai o r reuocafion <br /> of the license. <br /> y <br /> FURTHER AFFIAN7 13AYFTH NOT except that this Affidav t and Consent Statement are submitted in support of the. <br /> ication from the Lawful Gambling Control Board. <br /> rL <br /> R! r"Z;Ey COUNTY <br /> My Comm.Expha Jine 2,1994 <br /> -, ''�' f r i•S i i�r a 1 r <br /> his (Signature of applicant-Bingo Mall Personnel) <br /> EA ay <br /> A&I of <br /> Nar;e of Bingo Hall <br /> i <br /> Notary Public Bingo Hall License Number <br /> My commission expires <br />