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J <br />(Pursuant to Mnnesota Statute 349.16, Subd. 2e) <br />4a 41L V%, <br />a n't1iin the previous <br />under oath state tht V <br />name) rivel years: <br />(t)P,,1e/Prffit1 <br />1. 1 have not been convicted in a federal or state court of a, felony or gross nuisdemeanol <br />TqM M MM., <br />3. 1 have not had, a license issued by the Lawful Gambag, Control Board or Dkector revoked for g <br />m,e I as <br />By signature of' this document,, the undersigned authofizes the Depar=ent of Public Safety to con- <br />duct, a, cn*rm*,n,al background, check or reviewi and to, sh= the, results with the, Lawful Gamblm'g <br />A-8 0=11 6 9-Mall =I. U <br />F'ailm to proviWe requhrd irdormaidon or Providing fes,e or mWeading, information may result in <br />the derd"O, or, revocation of the license. <br />1-3 t 114 <br />�M P • <br />jgf ) -r-o *.,,. LM t"j- L., v%. Yc %.i t% A r i r\ Try, %I <br />N=e of Organization <br />