Laserfiche WebLink
„ L0200B <br /> ita LauLful Oan�blirW <br /> Org aeration Officers Affidavit <br /> STATE OF Minne s o t a AFFMAVIT OF QUALIFICATION <br /> s.s• OF OFFIMS FOR <br /> ORGANIZA71ON LICENSE <br /> COUNTY OF Ramsex. AND CONSENT STATEMENT <br /> (pursmt to nnesota Statute 349*16,SubdL 2e) <br /> 1, Pau Bauer +under oath state that within the pmvioua <br /> (typdprint one five years: <br /> 1} 1 have not been convicted in a federal or stag court of a felony or gross misdemeam. <br /> 2 I have near been convkted of a crime involving gambling, <br /> 11 have not had a license issued by the Lawful Garnbling Control Board or Dbww rev0W for a <br /> violation of law or board rule, <br /> in addition I understands agm and hereby o mmnt that suits and actions relating to the subject natter of xhe <br /> organization license application,or acts or ornissions err Ing from such application,n may be cornmenced against any <br /> organi on and I will accept the service of process for my on In any court of competent jurisdiction in <br /> Wmesota by mice on the Minnesota Secretary of Mate of any summons, or pleading authorized by the laws of <br /> ta. <br /> By signmure of this docurnenk the;undasigned authorizes the Deparmnt of Public Safety to conduct a aiminal <br /> background chi or review and to share the results with the Lawful Gambling Conti Board. <br /> Failure to provide required infomuttion.or provkfing false or misleading information may result in the derma or revoca- <br /> tion of the license. <br /> FLIRTHER AYFIANT SAYETH NOT,except that this Affidavit and Consent Statement are submitted in import of the <br /> lication for an orsan on lk=w from the Lawful Gambling Control JfoanL <br /> CC4"Oa Z66L,.'Loou"�L� <br /> signature `applicants , <br /> NOTARY Y FT. BLI DqF R A' ION APPLICANT I F RMATION <br /> otary yubnc must be current and correct. <br /> Seal mat► be altered. Chime Executive "�cer Ja Treaum(3 <br /> Effective date of officer dtange 0 6 / 01 / <br /> Nome Address <br /> ubsmlkd and sworn to before me this 2479 Dunlap St. Ho. <br /> city <br /> OW Roseville - <br /> .08y 0f.J 19. <br /> Mate e <br /> Minnesota 55113 <br /> Phone ( 612 )490-3056 <br /> Date of Birth <br /> dr <br /> Name of Orgmdution <br /> P a <br /> MA”"H UNTY Roseville Area Youth Hock <br /> License Number <br /> A-03 19 1 <br />