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— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — <br />I 0 We will not be renewing this person as gambling manager. Enclosed is a separate LG212 application I <br />Note: A new gambling manager may not assume duties until licensed by the Gambling Control Board. I <br />- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 <br />GM License #: 03191 -002 <br />Gambling Manager: <br />Home Address: <br />Phone: <br />Date of Birth: <br />Social Security #: <br />Bonding Insurance Co: <br />Bond #: <br />Most Recent Education: <br />April E Borash <br />10187 John Tr, <br />(651) 213 -6880 <br />Western Surety <br />58496640 <br />5/29/2003 <br />1. I have never been convicted of a felony or a crime <br />involving gambling. <br />2. I have never committed a violation of law or Board <br />rule that resulted in the revocation of a license issued by <br />the Board within five years before the date of the license <br />application. <br />3. I have never been convicted of a criminal violation <br />involving fraud, theft, tax evasion, misrepresentation, or <br />gambling. <br />4. I have never been convicted of (i) assault, (ii) a <br />criminal violation involving the use of a firearm, or (iii) <br />making terroristic threats. <br />5. I have never been, or am I now, connected with or <br />engaged in an illegal business. <br />6. I have never had a sales and use tax permit revoked <br />by the commissioner of revenue within the past two <br />years. <br />7. I have never, after demand, failed to file tax returns <br />8. I do not owe $500 or more in delinquent taxes as <br />defined in section 270.72. <br />9. I have been an active member of the organization. <br />10. I am not a gambling manager or an assistant <br />gambling manager for another organization. <br />11. I am not a lessor, a member of the immediate <br />family, or an employee of a lessor of a premises where <br />this organization has a permit issued from the Board to <br />conduct lawful gambling. <br />12. I am not involved directly or indirectly as a bingo hall <br />owner, manufacturer, or distributor. <br />13. I am not the chief executive officer of this <br />organization. <br />14. I am not the treasurer of this organization. <br />3 1, <'007 <br />Chisago, MN 55013 <br />Background Check By signature of this document, the <br />undersigned authorizes the Departments of Public Safety and <br />Revenue to conduct a criminal and tax background check or <br />review and to share the results with the Gambling Control <br />Board. Further, I understand, agree, and hereby irrevocably <br />consent that suits and actions relating to the subject matter of <br />this gambling manager license application, or acts or omissions <br />arising from such application, may be commenced against me or <br />my organization and I will accept the service of process in any <br />court of competent jurisdiction in Minnesota by service on the <br />Minnesota Secretary of State of any summons, process, or <br />pleading authorized by the laws of Minnesota. <br />Failure to provide required information or providing false or <br />misleading information may result in the denial or revocation of <br />the license. <br />I have read this application and declare that all information <br />submitted is true, accurate, and complete. <br />Notariz. signature of gambling manager applicant <br />Date: /r` /. I — C. <br />Notary Public Seal must be current and correct; seal may not <br />be altered. Subscribed and sworn to before me this <br />Notary <br />day of _ L�'C-%k,-- Zeta � <br />