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�� �''` .� .... ��° �� Minnesota Lawful Gambling `��=��y-` ��4�y�, (i.GZ04R} Lawful Gambling License Renewal Application �Corrections should be made directly on this application S•••••••••••••••• ' , Submit one check for all renewal fees, payable to State of Minnesota � Organizationrequirements: Current license term: 1/1/2006 to 12/31/2007 1. An annual organization license fee of $350 is required Authorization: 3191 Organization: RoSeville Area Youth Hockey ASSOC 2000 Greenbrier St, Maplewood, MN 55117 CEO: Barbara ,�ean Suciu Treasurer: Annual Goal for Charitable Contributions � Gambling Manager Requirements: 1. An annual gambling manager license fee of $100 is required. Renewing license tEr1'�1: 1/1/2008 to 12/31/2009 . j tiiie_k �iin U'v� �� f � "' '�r�a•:s�l�.�aqualifiesfor � ! the waiver Of the $35R � Cvur�C}�= Ramsey 1 c��,�d+nr►�tra�ta�� : L __�.349.16{��3:n_ J Gambling ManagerAuthorization: GM-03191-002 �� n� T�in?� ��2�� g �?�� '- The individual listed is not renewing their license. V�k have endosed a LG212 --' ��..�� '�r.ti for the new applicant. � Note: The gambiing manager duties may not be assumed k�jr an - individual.until they are li�ensed by the Minnesota �-�...� - , C�ambling Conhol Board. Gambling ManagerAffidavit and Consent Statement 1. I have never been convicted of a feiony or a crime 12. I am not involved directly or indirectly as a bingo hail owner, invoiving gambling. manufacturer. or distributor. 2 I have never committed a violation of law or Board.rufe 13. I am not the chief executive officer of this organization. that resulted in the revocation of a license issued by the 14. 1 am not the treasurer of this organization. Board within five years before the date of the license 15. I was not an officer of an organization at a time when an application. offense occurred which caused that organization'slicenseto be 3. I have never been convicted of a criminal violation revoked. invoiving fraud, theft, tax evasion, misrepresentation, or BaCkground CheCk. By signature of this document, the gambling. undersigned authorizes the Departments of Public Safety and 4. I have never been convicted of (i) assault, (ii) a criminal Revenue to conduct a criminal and tax background check or review violation invoiving the use of a firearm, or (iii} making and to share the results with the Gambling Control Board. Further, terroristic threats. I understand, agree, and hereby irrevocablyconsentthat suits and 5. I have never been, or am I now, connected with or actions relating to the subject matter of this gambling manager engaged in an illegal business. license appiication, or acts or omissions arising from such 6. I have never had a sales and use tax permit revoked by application, may be commenced against me or my organization and the commissioner of revenue within the past two years. I will accept the service of process in any court of competent 7. I have never, after demand, failed to file tax returns jurisdiction in Minnesota by service on the Minnesota Secretary of required by the commissioner of revenue. State of any summons, process, or pleading authorized by the laws 8. I do not owe $500 or more in delinquent taxes as defined of Minnesota. in section 270.72. Failure to provide required information or providing false or �. I have been an active member of the organization for at misleading information may resuCt in the denial or revocation of the least two years at the time of our organization's initiai license license. appiication, or I�ave been an active member for at Ieast the Changes in the information submitted i�s this appiication will be most recent six months prior to the effective date of our submitted in writing no later than 10 days after the change has organization's license renewal. taken effect. 10. I am not a gambling manager or an assistant gambiing , manager for another organization. ��ti� r�;� �,� ap�al��x� dr�1 cedare ��31 �II h7ft�nri� �� 11. I am not a lessor, a member of the lessor's immediate suhmtti.�d is �r a�cu � � d�ornylQte. family or a person residing in the same household as the —•-� -� -��- - lessor, or an employee of a I�ssor of a premises where this �i9n rcr in ink, of gambiing manager applicant organization has a permit issued from the Board to conduct � r�-� lawful gambiing. Date: J � ; .