Laserfiche WebLink
�a} <br />����-f Minnesota Lawful Gambling <br />�.�'�„,,, (�.G2001�} Lawful Gambling License Renewal Application <br />•� Corrections should be made directly on this application <br />Submit one check for all renewal fees, payable to State of Minnesota <br />.................: <br />; Boardl.k�{'�•� <br />� <br />Organization requirements: Current license term: 1/1/2006 to 12/31/2007 <br />'I. An annual organization license fee of $350 is required. Renewing license term: 1/1/2008 ta 12/31/2009 <br />Authorization: 70 <br />OrganiZation: Midway Speedskating Club I�C <br />2780 Snelling Ave Ste 107, Roseville, MN 55113 <br />CEO: Michael Daniel be�ranCa <br />'Freagur�r: – ' _. , . <br />Annual Goal forCha�-i���� Contributions � � °�a <br />Gambling Manager Requirements: <br />'I. An annual gambling manager license fee of $100 is required. <br />�aur�tyr: Ramsey <br />— � Chx� �'+E 44� if your � <br />"' ; Of�l1¢8fi011 qt�aiifies for € <br />I the waiver of the $350 I <br />' organization license fee <br />i defined in MN Sfiahat2 � <br />, _3a9.i5 �„lr��—J <br />Gambling ManagerAuthorization: GM-00070-0� ��r�n� Li�ens����= 1/1/2006 to 12/31/2007 <br />I�cr�etik�i�7[� li��n�� �erm: 1/1/2008 to 12/31/2009 <br />3T':1 The individual listed is not renew�ng their license. We have endosed a LG212 <br />appiication for the nani app[icant. <br />`° -•– T• � `" ••� Note: The gambiing managerduties may not be asaimed by an <br />individual un�it they are licensed by the Minnesota <br />Gambling Control Board. <br />Gambling Manager Affidavitand Consent Statement <br />1. 1 have never been convicted of a felony or a crime <br />involving gambling. <br />2. I have never committed a violation of law or Board rule <br />that resulted in the revocation of a license issued by the <br />Board within five years before the date of the license <br />appiication. <br />3. I have never been convicted of a criminal violation <br />involving fraud, theft, tax evasion, misrepresentation, or <br />gambiing. <br />4. I have never been convicted of (i) assault, (ii) a criminal <br />violation involving the use of a firearrn, or (iii) making <br />terro risti c th reats. <br />5. 1 have never been, or am I now, connected with or <br />engaged in an illegal business. <br />6. I have never had a sales and use tax permit revoked by <br />the commissionerof revenue within the past two years. <br />7. 1 have never, after demand, failed to file tax returns <br />required by the commissionerof revenue. <br />$. I do not owe $500 or more in delinquenttaxes as defined <br />in section 270.72. <br />9. I have been an active member of the organization for at <br />least two years at the time of our organization's initial license <br />application, or have been an active member for at least the <br />most recent six months prior to the effective date of our <br />organization'slicense renewal. <br />10. I am not a gambiing manager or an assistantgambling <br />manager for another organization. <br />11. 1 am not a iessor, a member of the lessor's immediate <br />family or a person residing in the same household as the <br />lessor, or an employee of a iessor of a premises where this <br />organization has a permit issued from the Board to conduct <br />lawful gambling. <br />12. I am not involved directly or indirectlyas a bingo hall owner, <br />manufacturer. or distributor. <br />13. I am not the chief executive officer of this organization. <br />14. 1 am not the treasurerof this organization. <br />15. 1 was not an officer of an organization at a time when an <br />offense occurred which caused that organization's iicense to be <br />revoked. <br />�a�9c�ro��a�! Check. By signature of this document, the <br />undersigned authorizes the Departmentsof Public Safety and <br />Revenue to conduct a criminal and tax background check or review <br />and to 5hare•�he results with the Gambling Control Board. Further, <br />I understand, agree, and hereby irrevocably consent that suits and <br />actions relating to the subject matter of this gambling manager <br />license application, or acts or omissions arising from such <br />application, may be commenced against me or my organization and <br />I 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 pleading authorized 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 appiication will be <br />submitted in writing no later than 10 days after the change has <br />taken effect. <br />I have read this application and declare that all information <br />{.�_�nitte� rs� e, aca�rate, ar�d I�- <br />�'��°'��—�} �%�_� '� <br />�;i_nah�re, in ink, aFcsambling rr.�nasl�r aI�I�G����l <br />Date: � I � � I � �� <br />