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Minnesota Lawful Gambfing
<br />Conftoi (LG200R) Lawful Gambling License Renewal AppHication
<br />corrections should be made directly on this apptication
<br />Submit one check for all renewal fees, payabie to State of Minnesota
<br />Organization requiremen't.,cm., Current license term: 4/ 1/ 2006 to 3/3 f/2008
<br />L An annual organization license fee of $350 is required. Renewing license term.- 4/1/2008 to 3/31/2010
<br />.... I !A&�
<br />Authorization #me 1878
<br />Organization,*, North Ramsey 500 Lions Club Inc
<br />Box 17031, St. Paul, MN 55,117
<br />, CEO:
<br />io el
<br />Gambling Manager Requirements.
<br />An annual gambling manager license fee of $1.00 is required,
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<br />Gambl!" g Manager AuthorizabV,-,-7
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<br />Ronri,
<br />Current License Term l� 4/1/2006 to 3/31/2008
<br />Rene ling license term-, 4/1/2008 to 3/31/2010
<br />inlAv"I'alu-'al listed is not reiiewing their license. We. have endosed a L� 2,
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<br />ication for the nevv applicant.
<br />Note.- The gambling manager dubes may not ke-�-S�U- med by an
<br />it ]UM Udf 0 say i t: Ticense by ty,716nesuLd
<br />Company.
<br />Gamblinc; Control Board.
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<br />Gambling Manager Affidavit and Consent Statement
<br />I I have never been convicted of a felony or a crime
<br />involving garnbling.
<br />2- 1 have never committed a violation of law or Board rule
<br />that resulted in the revocation of a license issued by the
<br />Board within five years before the date of the license
<br />application,
<br />3. 1 have never been convicted of a criminal violation
<br />involving fraud, theft, tax evasion, misrepresentation, or
<br />gars tiling .
<br />4, 1 have never been convicted of (i) assaultj, (H) a criminal
<br />violation involving the Use of a firearm, or (iii) making
<br />terroristic threats.
<br />5. 1 have never been, or am I now, connected with or
<br />engaged in an illegal business.
<br />6, 1 have never had a sales and use tax permit revoked by
<br />the commissioner of revenue within the past two years.
<br />T. 1 have never, after demand, failed to file tax returns
<br />required by the commissioner of revenue.
<br />8, 1 do not owe $500 or more in delinquent taxes as defined
<br />in section 270,72.
<br />9. 1 have been an active member of the organization for at
<br />least two years at the 0-ne of our organization's initial license
<br />application, or live been an active member for at least the
<br />most recent six Months prior to the effective date Of OUr
<br />organ�zationls license renewal.
<br />10. 1 am not a gambling manager or an assistant gambling
<br />manager for another organization,
<br />11* I am not a lessor, a member of the lessors immediate
<br />larnify or a person residing in the same household as the
<br />lessor, or an employee of a lessor of a premises wher e. this
<br />organization has a permit issued from the Board to conduct
<br />lawful gambling,
<br />12, 1 am not involve, d directly or indirectly as 4,1i ngo h%Ap' r,
<br />manufacturer, or distributor. 0 UP4
<br />13. 1 am not the chief executive of of this
<br />14, 1 am not the treasurer of this organization.
<br />15., 1 was not an officer of an organization at a time"'Wh�h �a n
<br />offense occurred which caused that organization's liven se'to ,be
<br />revoked.
<br />Background Check. By signature of this decument, the
<br />undersigned authorizes the Departments of Public Safety and
<br />Revenue to conduct a criminal and tax background check or review
<br />and to share the results with the Gambling Control Board. Further,
<br />I understand, agree, and hereby irrevocably consent that suits and
<br />actions relating to tie subject matter of this gambling, manager
<br />license application, or acts or ornissions arising from such
<br />application, may be commenced against me or my organization and
<br />T will accept the service of process in any court of competent
<br />jurisdiction in Minnesota by service on the Minnesota Secretary of
<br />State of any summons, process,, or pieading authorlized by the laws
<br />of Minnesota,
<br />Failure to provide required information or providing false or
<br />misleading information may result in the denial or revocation of the
<br />license.
<br />Changes in the information submitted in this app5cation will be
<br />submitted in writing no later than 10 days after the change has
<br />taken effect, � "/ 140:7 Ae
<br />I have read this application and declare that all information
<br />submitted is true accurate, and complete.
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<br />Signature, in ink,, of gambling manager applicant
<br />Date:
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