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mi is"t liwAm.1%pli vit:qluirements': I Anannual Organization 111cense fee of $3501s required. Authorization *;- 113 OrgOnizationi, AmeNcan Legion Post 542 Roseville 700 W Co Rid C, I ROSeVille, MN 59113 CF Treasurer, Gambling Manager Requ-Ir err entsif 1. An annual gambling manager license fee, of $100 Is required, Current-IiCen$e term, 2 R�n rn license term III PET Ch k this �dx if YQVr Annual Goal for Charitable CO,ntributions orgy RVation qu air nes tor I trot w9liver Of the $350 Organization lloen:s� fee de'tined in MN Stattjtrt! Gambling GM-0101:E3-006 Current Ucense Term - W1/2007 to 2/219/2008 Renewing lise cen term.' a/l/2008 to 2/28/2010 The IndivIdual listed Is not riersewing their lime. We have enclosed a LG212 ViPllcatioin for the new appiicantl, N10tia: The gambling manager dutles may not be assumed by a�r) IndivilduaJ until they are licensed by the I minnesiota aarnblin5 ContTiol BoardA 't and Consent Statement Gambling ManiagerAffid M I. I have n6ver been convicted of a felony qrl crime ;nvolkling .0ambling, 2. 1 have never committed a violation of law or Board r' Ahat resuited J11n the revo cation of a license fld by the DOW within five years before the date of the license application.. 11 have never been convicted of a criminal violation involving fraud,, theft, tax evaslonr miSreprtsentaflon, or gambling. 4. 1 have never been convj*ded of (i) assaultr 06 a ctiminal 11 violation, involving the us'e of'a f7milarm, 6r 00 making". terroristic threats, 5, 1 Ihave never beeni, or are I now, connecte . d with or engaged In zin illegal business. 6, T have nev'8r had 6 Sales and use tax permit revoiked by the commissioner of revenue wlithin the pest tiro years. 7, 1 have never, after dem6nd, failled"to file tax re Wrns I required bY the COmmissioner of revenue. S. I do not owe $500 or more in dellinquent taxes as defined in rein 270.72- 9. 1 have been an activin member the organization for at least two years at the time of our organizotion',s initial license application, or have been an active member far at least the most recent six months l prior to thle e0edive date of our organization's license renewal. 10,1 4 M . I ding manager or an asni=nt giambiling amnot a less i o )X * - ernWr of the lessor's immediate ly r�_"A pil,�7 0 residIn in the same household as the r CV sSio r l esw of remi r�Oloyee a Pses where this in n perm rni reed frOm the Board to cuiriduct (4 Ja Ul 1 '70- Z Z" % 12. 1 am not i,nvolved direcdy or inidiredly as a bingo hall ownlert msnufm. u err. or rl rbtAor. am not the chief exeriutive offirer OF thl$ t)rganjzat� am not the tmasurer of this ol I It son. rganization. was nQt an officer of an organiZation at a time wh jl an offense occurred which Caused that Qrqan1Zabc)r1,s 1, [Cense t0i ble revoked. Background CWck. By sl0aWre Of this dolmment, the undersigned authorizes the Departments Of PONIC Safety erid Revefte to conduct a criminal and tax background check or revi and to share th8 results with the GambliN Control Soar, Further, I understand, agree, and hereby irrevocably consent that suits and actions relating to the $UbjeLt matter of this gambling m- �,anager license application, , or acts or omissions aftng from such aPPlicaWnI, may Ibe commenced against me or my organization and I will accept the service, of process in an' y court 6r cornpetent jurisdiction in Minnesota bY 58rvl on the M�inne$ota Secretaryl of State Of an suMmons, process, or pleading authorl by the laws of Minnesob. FallUre to pro Vide required Wor mat ion or providing fOlse or. I I misleading nformation MY. result in the denial or revocation of the license. Changes in the informiation Submitted in this application Will be SUbMitted in wrtting no later than 10 days after the change has taken effact. I have read this applit:zjtlon and declare that all stibirt fft P-A i q-4 r" --*A - - i*A .?I Signature, Yin in,k ciamblIrIg man ager applicant J .All Date: leoe I I 71) In or