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.,Lye. <br />W F 1 Lawful Gambling <br />-Organization Officers Affidavit = L020091 <br />State of Minnesota } <br />5S. <br />County of Ramsey <br />Affidavit of Qualification of Officers <br />for an Organization License and <br />Consent Statement <br />(pursuant to Minnesota statutes) <br />(please print) - - g o n e t h -D a man -„ - - - -M, under oath state that: <br />ll <br />1 . I have not been convicted of a felony or gross <br />misdemeanor YAthin the five years before the issuance <br />or renewal of the ricense. <br />2. 1 hive never beein convicted of a crime lhvolving <br />gambling. <br />3. 1 have nearer had a license issued by the board or director <br />pdrrnanently revoked for violation of law or board rule. <br />In additidn, I understand, agree, and hdreby Irrevocably <br />consent that suits and actions Acting to the subjek t matter <br />of the organization license application' or acts or omisslens <br />arising from such application, may be commenced against <br />ray organization and I will accept the service bf process for <br />my organizaUari in any. court of competent jurisdiction In <br />Minne .sota by 'service on the Minnesota Secretary of State <br />of any . summonsr process, or pleading autho fted by the <br />laws of Minnesota. <br />Appiieant'informatic)h . <br />Check the box. indrcatlng'your position: <br />chief' executive officer Treasurer <br />Effective date of officer change <br />Morn address iffiffiffil <br />c <br />State0p code Mfg 5-5113 <br />Is this the business addres's of your organization? yds ET no <br />Phone 4OMPw 9INDIBNAEL <br />Name of organization Lady Sli er Ch lot A$W <br />Base license number #03162 <br />This form will be made available in altemaUve format (i.e. large <br />print, Braille) upon request. Call the t.icansing Section of the <br />Gambling control Board-at 6511 639 _4000 if you have gUes #inns <br />about this form. If you use a TTY, you can call us b y g usin the <br />Minnesota Belay Service at I �BOU27,3529 and ask to place <br />call to 651-639-400o. <br />By signature of this document, the undersigned authorizes <br />the Department of Public S a f e'ty to conduct a criminal <br />background check or review and to share the results with <br />thd. arrhbling Control Board. <br />Failure to provide required information or providing false or <br />misleading information may result in the denial or revocatio'n' <br />of the license. <br />FURTHER AFFIANT SAYETH NOT, except that th is Affidavit <br />and consent Statement are submitted in support of the <br />application for. an organization license' from the Gambling <br />Control Board. <br />(Applicant Signature) <br />Notary Public Information <br />Notary Public Seal -must be current and correct. The <br />seal may not be altered. <br />B ubscdbed and sworn to beford m a thi s da y of <br />(rotary Public Signature) <br />�; MAWEEN DAMMAN <br />* y s 7 <br />p - NOTARY PUBUC- MINNESOTA <br />MY CO mission Expims.juL 31, 2005 <br />Mail this form to: Gambling Control Board <br />-Suite 300 South <br />iyi West County Road B <br />Roseville, MN 55113 <br />The information requested on this form will become public <br />in' for'matiQn Men received by the board, and will be used to <br />determine your compliance with Minnesota statutes and rules <br />governing lawful gambling activities. <br />8100 <br />