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, L ate WIi <br />R under oath state that *thin. the, previous <br />0 <br />(type/print name) flve years. <br />1111liq <br />L "il _71-WITWMIS �_. 0011 1M. <br />3. i have not had a license issued by the Lawful, Gambhng Control Board, or IXwector revoked for a <br />MIS ro 99716T.714VIn <br />In addition, I understand, agree and, hereby irrevocably consent that suits, and actions relating to the <br />subject matter of the org :Antion, ficiense application, or acts or o="ssions ansing from such applica <br />tion, may be commenced agm'nst my orgi "wat6on and I wW accept the serle of'process for my <br />org,=zadon m any court of competent, jolsdiction M' Minnesota by service on the Nfinnesota Secre*W <br />tary of'State of' any summons, process orl pleading authon"Ized by the laws ofMinnesota. <br />By sagna=e of' this document, the undersiled author=*si the Department of' Public Safety to con- <br />d,uct a Cnrm,nal background check or review and to share the results with the Lawful, Gambling <br />,a <br />Rodlure tol provide requirled, informadon or providing f9se or, n mWeading Wormation may result W"I <br />ale denial or revociation of the Hcense% <br />T714 F7 r. r-, . MO) 7M • 0 -7 (a —11 - f T <br />(e!5 day of <br />... ............ <br />, L -Or r% <br />046 .......... <br />..Y <br />Nme, of Orgmizadon <br />II <br />