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"�-=-- ,_--�.y 'G-:°,':' � ................. � , Mir�r�esota Lawfuf Gamb�ing � : gdar��Seo�EY ; Ga�nbEing ��pp�� wfu�� Gambling License Renewal Application Control Corre�i�ns st�o�Ed be made directly on this appEication ------------------ - Submit orte cheek Por all renewal fees, payable to Siate of Minnesota �rgani�ati�� requirern�nts. Curre�i license �erm: i Q/1/��5 �0 9/3�/��7 1. An annual arganization }icense fee af $35D is requlred. R��t�tNiE1g iiC�nse t�r�'1: 10/1J20�7 tn 9/3�%2n49 I�U��'1Q1"IZc��IUEY: �.% Organ�zatiaat�: 1��W �ost i555 RosevilE2 1�95 Waodhill Dr, Roseville, MN 5511� CEU: Gien �eRay Faciden Tr�asurer: J� A�r�ual Gnai for Ch�aritable �onirihutions % G�mbling Manager �tet�uirement5: 1. An ann�ai gambling manager licens� fee of �iQO is reqttired. (612)483-5313 County: Ramsey .. _ _ __... ..._ ....� ..... .._ . l�� Che[k thls bax if yaur � �'I ,organlzation quaflfles for 4 � the walver of the $3SD � organization Ilcense Pee E � defined' in MN 5tatute k �. _ _ 349.1fi Subd__ 6 ,_. __ ,, Gambiir�g Mae�ager A�thoriza�iort: GM-0009.i-ODf Cur�ent Licet�se Terttro: 1�/1/2045t� 9/3�/�OQ7 R�tiGWi�'1t,� I{C�i1S@ �Li'It'9: 10/ 1 f 2tftli to 9 j 30/ 2p�9 Michc�ei Ftal�k ThUrv �„ ihe individual listed is nat renewing their license. 4�/e have �nclosed a LC212 ap�lication for the new appli�ant. hEate: The gamb(ing manaqer duties may not be assumed by an individual until they are licensed by Che Minnesota �" Gambling Contsol Board. Gamblit�g Mana�er Affic�avi� ant� Con�ent �tatetttettt 1. I ha�e never bee� convicted af a felony or a crime 12, i a€n �iot fnvolved directfy or ind'trec�ly as a bingo hall owner, invnlvirtg garnbling. manufac�urer, or distributc�r. �. I have never ca�mihhed a vialatian of law or 8nard rule 1�. T am not the chief execu�ive of�cer of this ar�anizatian. that resulted in the revocation of a license issued by the 14. I am nr,t the treasu�'er of �his organization. Boatd within five years befvre the da�e of the lic�nse 15. i was no� an af#icer of an �rganization at a tlme when an application, o�fense occ€�rred which caused that organizatio�'s lice�se to be 3. I have never been convicfied af a crirninal v'salation revoked. in�ol�ing fraud, theft. tax evasiar�, misreprese�ta�ion, ar �aCi��otlttd CheC�C, By signature qf this document, the gambEing, undersigned a�thorizes the Departm�n�s nf Pub{ic Safeiy and 4. i have never been �onvicked af (i) ass�€�It, (ii) a criminai Re�en�e �o conduct a criminal and tax background eheck or review viofatipn i�volving the use of a�rearm, or (iii) €r�aking and to share the res�lts wjth ihe Ga�b4is�g Cas�trol �oard. �ur�her, kerrorist€c threats. I ur€derstand, agree, and here�by irre�ocabEy consent that sui�s and �. I have never been, or a€� I now, con�tected with or actions r�lating io the s�bject matter a€ ��is gambling manager engaged in an illegal �usiness. license appiication, or ac�s or omis5ions arising frarn such 6. I have never had a sales and use tax permit r�vo�Ced by �ppiicatian, may be commenced against me or my organizat[an and t�e cofnmiss'soner of revenue v+rithin the pasfi two years. I will accept �he service of process in any co�rt oF eompetent 7. I have never, atter dernand, failed ta fie tax returns jurisdiction in Minnesota by service on th� Minnesota Secre��ry of required by th� commissianer of reve€�ue. State of any summons, process, or pleading a�thorized by the laws 8. I do nnt �we $50q or rnore in d�Pinquent iaxes as defned �f Minnesnta. in sectian �ip.i2. Failure ta prc�vicle requirec! infarmat'�on or pro�iding �'alse ar 9. I have be�n an active mer�ber af t€�e organization far a� mis3�ading information rr�ay result in the c#enial or re�cscatinn of the least two years at the time af ac€r organizafiion's initial license lieense. app�ication, or have been an ac�ive member far at faast the �hanges in the informa�ion subm€t�ed in tf�is app�icatian wilE be mas� recent six months prior to the effec�ive date of aur submitted in writing no later t�an if1 days after the change has arga�iza��nn`s 4ice�sse renewal. kaken e�#ect. 10. I am not a garnbling manager or an assis�ant gambling I have read this applitation and declare that afl informa�ion rnanager for anothe� arganization. 1�.. I am not a Iessor, a member of the lessor's imrr�edia�e submi�ed is ��ue, ccurate, r��,gmplet family or a person residing in the same household as t�e I�sso�, or an employee o� a lessor of a pre€nises where �his Signature, in ink, af gamblfng manager appii ant o€-ganization has a permit fssued from the Board to conduct lawful gambling. Date: ��/�/ !� � `