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go <br />LG2008 <br />(7M"I) <br />Ani�honly Lee Borash, 0 a �Z-4 <br />under oath, state that Within die previou <br />W <br />(typelprint name) five yeara, <br />1. 1 have not been convicted m a, fedaml or state court of'a, felonyi or gros's MiSde neanor. <br />2. 1 have never bee'n convicted, of a cd= involving gambling. <br />61 <br />31MI 1 have not had a license issued by the Lawful Gambling Control Board or Director revoked for <br />OMI !IIIIIIiiiiiiii liq 11111��111111�1111 <br />IT <br />, 11 111! 111 111 <br />Ih Affition, I understand,, agme and hereby ="vocably consent that suits, and acnions relating to the <br />ation or, acts or orm4lssio,n,s, ans*ng from such applica <br />subject matter of' the organization license applic, <br />,e <br />tion, may be conmenced against my organ Lzation and I will, accept the service of process for MY cal <br />MI I dic - n 'n, Minnesota biv serviice on the AEnnesota Secre <br />zation in any court, of competent jun,s itio i <br />tary of State of any summons, process or, pleading authorized, by the laws of NUanesota. <br />By signature of this, document,, the undersigned authorizes the Depl=nent of'Public Safety to conAM <br />luct, a criminal, back und -check" or review and to share the results WIfth the Lawful Gambling <br />Control, Board. <br />,a <br />Failure, to provide requfird infortnation, or p i <br />roviding false or misleading informadon may result in <br />the denial or revocation of' the license. <br />FUR=R AFRANT SAYETH NOT, except that this Affidavit and Consent Statement are subnuft. <br />ted, m support of the app * uon, ror an organization license from the Lawful Gartblm*g Control <br />ROTS"to <br />I fir?" <br />11 1,10 0.' <br />day of (�I <br />. 11, $� <br />i .., f. <br />A <br />7t <br />k Aw. <br />- <br />Wv�v <br />< 01 <br />V V VO I a P I a FK FINBERG <br />IINNESOTA <br />NO T'A Y <br />, ;_t?t <br />A - 'nom """ N KIII, I i Ca G U 4`11 T'Y <br />%WfV"~J%VW <br />(Sivoraftm Of ap�iicant) <br />El Chief Execufive Officer 0 Trmurer <br />Roseville Area, Youth Hock # IP <br />ey- Association <br />Name, of Organiza,fion, <br />A�-03191 <br />Lices ise Number <br />