Agenda - Council - 05/14/1991 - Laserfiche WebLink

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LG200B (11/19/90) Minnesota Lawful Gambling Organization Officers Aftidavit STATE OF frt t ~/..J ~ ~.c~,A -) COUNTY OF (type/print name) AFFIDAVIT OF QUALIFICATION OF OFFICERS FOR ORGANIZATION LICENSE AND CONSENT STATEIvlENT (Pursuant to Minnesota Statute 349.16, Sub& 2e) , under oath state that within the previous five years: 1. I have not been convicted in a federal or state court of a felony or gross misdemeanor. 2. I have never been convicted of a crime involving gambling. 3. I have not had a license issued by the Lawful Gambling Board or Director revoked for a violation of law or board rule. In addition, I understand, agree and hereby irrevocably consent that suits and actions relating to the subject matter of the attached organization license application, or acts or omissions arising from such application, may be commenced against me in any court of competent jurisdiction in Minnesota by service on the Minnesota Secretary of State of any summons, process or pleading authorized by the laws of Minnesota. By signature of this document, the undersigned authorizes the Department of Public Safety to con- duct a criminal background check or review and to share the results with the Lawful Gambling Control Board. Failure to provide required information or providing false or misleading information may resutt in the denial or revocation of the license. FUR2I-tER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submit- ted in support of the application for an organization License from the Lawful Gambling Control Board. Subscribed and sworn to before me this Notary Public {~ignature of applicant) ~ Chief Executive Officer [] Treasurer Name of Organization mol License Number 31' I I I I I I I I I I I I I I I Ii I I