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J&nes Lpee Wamer a under oath state that Within the previous (typelprint namei) five years,, 1. 1 have not been, convicted "in a federal, or state court of a, felony or gross misdemeanor. 0 a 2. 1 have neveri been, convicted, of a c=e involving gambling.1 I have not had a, l,icensei, issued, by, the Lawftil Gambling Control, Board, or Director revoked for7, ICI 1 it scamrorn In adiditilon,, I understand, agree and hereby irrevocably consent that Suits, and actions relating to the subject matter of the organization, license application, or acts or onnissions ansing from such applica- MI tion,, may be commenced against my organt ation, and I will accept the serv.ice.of process for my organization in any coun ofcompetent jmisdictioin in Minnesota, by serie on the NUnnesota Ser-i tary of State of any s , ons, process or pleading authorized, by the laws of Mnnesota. By signature, of this document, the undersigned authorizes the Department of Public Safety to con- duct a MMInal. background, check or, review, and to share thei results Wl"th the Lawful Gamb1Mg LW *=f I W 1 10, =W 0 41 10 0 L%ilure to provide required irdonnation or! prx)viffing, false or rmisieacung information may resi Oil thei denial. or revocation of the license V-iURTBIER,AFFIANT SA I NOT, except that this, Affidavit and Consent Statement are submit- ted "in zupport of the application. for an origanizan"on license from the Lawful Gamblmg Control Board. 'M 17- ny 1"1'14.14 1'*- E.....Aay of 6CM8M 19141 ON (signa=e of applicant) 0 Chief Executive Officer 10 Treasurer Name ofOrganizanioni A-1013191 License Number,