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r t-W-A- <br />j (please p r[nQ Debra B u rc: h e t t under oath stag that: <br />1. 1 have not been corkvicted of a felony or gross <br />misdemeanor within the five years before the issuance <br />or renewal of the license., <br />2. 1 have never been convicted of a crime involving <br />gambling. <br />3. 1 have never had a license issued by the board or director <br />permanen ly revoked for violation of law or board rule. <br />In additidn' I understand, agree' and hereby irrevocably <br />consent that suits and actions la#Ing to the subject ma#ter <br />of the organization license application, or acts or omissions <br />arising from such. application, may be commenced against <br />my organization and i will accept the service bf process for <br />my organization In any. court of competent Jurisdiction in <br />Minnesota by 'service on the Minnesota Secretary of State <br />of any-summons, process, or pleading author ed by the <br />laws of Hnnerota, <br />Loop] <br />t Z 0� �* <br />E3 - - <br />Effective date of officer change <br />Aorne address <br />RY <br />New Brighton <br />State Op code MN - 5 5 1 1 <br />Is this tfte business address of your organization? yes no <br />Phone <br />Name of organ%tion_. Lady Slipper Ch t ABW <br />IR <br />Base license number #0 3 16 <br />By signature of this document. the undersigned authorizes <br />the Department of Public Safety to conduct a criminal <br />ba�found check or review and to -share the results with <br />t[�e. Gambling control Board. <br />Failure to provide required informalion or providing alse or <br />misleading 'Information may result in the g <br />] a denial or revocatip' n <br />of the license. <br />FURTH ER AFF1ANT SAYETH NOT, except that this Affidavit <br />� <br />and consent Statement are submitted ire support of the <br />application for an organization license from the Gambling <br />' control Board, <br />rip <br />(Applicant Signature) <br />Notary Public Information <br />Notary Public Seal-must be current and correct. The <br />seal may not be altered. <br />Subscribed and swo <br />before day of <br />C- � . <br />tNcta <br />{` my comrtfssion Expires jai n. 31,20M <br />*mimes <br />Mail this form to: Gambling Contra[ Board <br />-Suite 340 South <br />1711 West County Road <br />RQSEVIIIe, MN 55113 <br />j 1 114 iv{! l i Yvin Lac « sue avallaate Ln anemative to rmat (•e. large The i nfoimation requested on this form will become p Leh lic <br />print, Braille) upon request. call the Hcefting 8ecUon of the itiformatign mihen received b the Board and Will <br />Gambling control Board-at 651-639-4000 if you have questions determine - � Y � be used to <br />rm ne �QUr compftance with Minnesota statutes and rules <br />about this form. if you use a TTy, you can call us by using the goveming lawful gambling ac'kivr#ias. <br />Minnesota Relay Service at 1- 800-627 -3529 and ask to place a <br />call to 651.630 -4000. <br />8/00 <br />