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L02008 <br /> (7MM � f Ung <br /> �nn t <br /> org ization 0 fi cers Aff1davit <br /> S'TA'TE OF Minn e so t a A&TIY?AVIT OF QUALIFICATION <br /> OF OFFICERS FOR <br /> oRGANizA71ON UCENSE <br /> COUNTY OF Ramsey AND CONSENT STATEMENT t. <br /> (pmumt to bfiumwta Statute 349.16,Subd.,2e) <br /> James Lee Warner under oath state that within the p x"Ous <br /> (tit tee) five years: <br /> 1 1 have not beets convi d in a federal or state art of a felony or gross misdemeanor. <br /> 2. I have never been convicted of a Mme involving gamblLng. <br /> 3. I have not had a license issued by the Lawful Gambling 00Wr0l EOard Cr Direct0f fcvcked for a <br /> violadon of law or board rule. <br /> in tion,I mdetstand and h=bY+ ly consent that sups and actions relating to the subject math of the <br /> oqpnizadon license appHcadon,or acts omissions g fpm such application,maynnrnenced against my <br /> orWizWon <br /> and I will accept the service of press for my orpnization in any court of competent jueusdiction in <br /> e on the Minnesota Secretary of Stag of any summons, �or pi ng authorized by the laws of <br /> ��by�c <br /> des <br /> of f s�irnent,the undersigned auth�s the ent of Public Safety t1D conduct a criminal <br /> By�� amblin Control Eoard.' <br /> and check or review and to share ft results with the Lawful S <br /> Failure to <br /> vide required information or providing false or misleading information may result in the denial or revoca- <br /> tion of the license. <br /> SAYETH NOT,except that this Affidavit and Consent Statement are submitted in support of the <br /> appiki6on for an on lice from the Lawful CT=bUng Control Board. <br /> (signature of <br /> tur plJ* 0 <br /> NOTARY PUBLIC WFORMA'TION APPLICANT INFORMATION <br /> Wiry buc sew trust be current and erect. <br /> Chief F�ntive o <br /> Seal may be <br /> ait�d. � c3 �` E) <br /> Effective date of officer 2!= e <br /> Dome Address <br /> and s� �before nee this <br /> 1215 �u�er <br /> S211"N. bed City <br /> Roseville <br /> a2Q -0 of 1 State <br /> y 'Minnesota 113 <br /> Phone ( 612 296-7333 <br /> Gate of Birth <br /> Name of on <br /> BONNIE J. SCOTT Roseville Area Youth Hockey Assn <br /> NARY PUar�c WNNWW 4 <br /> ANOKA COUNTY License Number <br /> My can�rnlsslan m& A-03191 <br /> u, <br />