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U3 !, <br />3 <br />d <br />tC <br />Annual Gambling Manager Fee "of $'IBO�ret�Ci��d_ <br />I We will not be renewing this person as gambling manager. Enclosed is a separate LG212 application <br />— — — — Note A new gambling manager may not assume duties until licensed by the Gambling Control Board. I <br />— — — — — — — — — — — — — — — — — <br />GM License #: 00070 -003 <br />Gambling Manager: Karen Sandra Olson <br />Home Address: 2968 W Owasso Blvd, Roseville, MN 55113 <br />Phone: (651) 484 -2686 <br />Date of Birth: <br />Social Security #: <br />Bonding Insurance Co: Western Surety Company <br />Bond #: 68976503 <br />Most Recent Education: 4/23/2003 <br />Affidavit and Consent Statement <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 <br />by the Board within five years before the date of the <br />license 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 (1) 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 />required by the commissioner of revenue. <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 <br />hall 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 />_ ....:,L JEFF A. WELLEN <br /><' ".Af NOTARY PUBLIC- MINNESOTA <br />My Comm. Expires Jan. 31, 2005 <br />c <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 <br />or my organization and I will accept the service of process in <br />any court of competent jurisdiction in Minnesota by service on <br />the 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 />Nota zed s gnature of gambling manager applicant <br />Date: Z67-67-03 <br />Notary Public Seal must be current and correct; seal may not <br />be altered Subscribed and(, sworn to before me this <br />— d of b" 2M 3 <br />Notary publiL::;�/ 4 G / <br />