97-1169Council File # Q�
ordinance #
f;r �f�£t E {t, P
i P f ;i. .
li t�. [.., t Z'•, . i.�..
Fresented
Referred To
Committee: Date
35
RESOLVED: That application, ID �44765, for a Gamblinq Manager's License by Steven P.
Tibbetts DBA Church of the Zncarnation at the New Frontier Saloon, 230 Front
Avenue, be and the same is hereby approved.
Requested by Department of:
Office of License, Insnections and
Environmental Protection
BY: � ' ,, �k43�
Adoption Certified by Council Secretary
$Y� � t� �- . ��v�2�1 �
Approved by Mayor: Date U�5 4
Sy: �
Green Sheet $ 37921
RESOLUTION
CITY OF SAtNT PAllL, MINNESOTA
Form Approv d by C�ty torn
By: t�^��
Approved b ayor for Submission to
Council
By:
Adopted by Council: Date � . �y ��q*j
i GREEN SHEET
- 266-9132
7 O DEPARTMENT DIRECTOR
FON OCITYATTORNEY
� BUOGET �IRECTOR
� � MAVOR (Ofl ASSISTANT)
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
� -1 \
37�2�
MITIAWATE
� cm courvca
� C�TV CLERK
O FIN & MGT. SERYICES OIR.
�
Steven P. Tibbetts DBA Ghurch of the Incarnation requests Gouncil approval of
his application for a Gambling Manager's License, ID 4k44765, at the New Frontier Saloon,
230 Front Avenue.
Approve (A) or Re)ect
_ PLANNING COMMISSION __ CNft
_ CIB COMMI7TEE _ _
_ STAFF _ _
_ DISTRICT GOURT
SUPPORTS WHICH GOUNCIL O&IEC,TIVE?
Where,
PERSONAL SERYICE CONTRACT$ MUST ANSWER 7XE FOLLOWING QUESTIONS:
1 Has tdis personftirm ever worked u(Wer a contract fw this department?
YES NO
2. Has ihis persoNFirm ever been a ciry employee?
YES NO
9. Does this person/firm possess a skill not normally possessetl by any curreM city employeel
YES NO
Expletn 01! yes enswers on separete shcet anC ettach to green sheet
tOTAL AMOUN7 OF TRANSAC710N $
COS7/REVENUE BUDGETED (CIRCLE ONE) VES
NO
°UNDIfiG SOURCE ACTIVI7Y
'INANCIAL INFOFhiATION: (E%PLAIN)
�ae�. � v9zy
Minnesota LmUfuI Camb(ing
Gambling Manager Application
ase uc r
ScQ Y
FEE
GriK '
O�TE
INIT
,..,,.. -,...„ .. ..- ,, - - "�- - --. _ .. �
... -�,..;--_ �: ----:
r�e ��Appticatiort ' '
❑ New
� Rer.ev+al
` � 1 Ti 4"i
LAST NAME
Tibbetts
Give c'ats riat �e Nro-Cay 5�bting mana;er seminaz was completed. /_!_
lacadon of baining
(Gry)
11`q
Give Ca� of 72ining received wichin �`ree years pricr to �e �:e ot �e applicaoon lor renevral. 2 120 t 90
Lxa�onc(�alning W��-�=�r �'?i::nesoCa
..._...:...._. . .. . _ ... . . _ .. ... . .. . (c .... .. ..:......... ..... : •
lTiQ 27'�772 0T77tRiTOR . . . - . .
fiRST NAfdE MIDDLE NAME MAIDEN Oate o( Binh Sx.�Sec,vnry N�rber
✓
Steven ?atric�c 3J17/51 476-62=�869
G633 !,th ave. So. `ti: neapolls t�' Sa�'+0
MEMcEnSHIP: Date gamblirg mznaser'�ec�oe a memSer cf he organi:auon 2/ 17 / 79
�
Name ol CrSanizaicn
Church uf tia lr.c2r�2ticn
Adcress G�cfiSa:a Zip Code
3S1 � P� 2 25E7C .iV2. SO. .^.e:E�7D� i S �N �:.09
� �61� 3?"•-=�3�
Sex : ��.1 Mda ! remale
-:s::..
�ICEnSd N�1710Bf
:06 i°
F`one
�612 � $2?_
.... ...:.,..,.......:.� ..:...........:..::... .
:;:,. . .. .. .. ...:... ....."�
.. ..
`�QB� �af1.S�J� ' :. r;
-� A 510,W0 Gde4iy bond in favcr of ;he crc,anizaocn nutt be cbaine0 lor �e yamcfng manager.
Name of (nsurance campar.y (do nct use agenc� rsme� G S °icei-tv S Gu&r�nt3ond `umDer �-�'?0 �D-;vi0�^02-�
�AcJcnouiie�igr�ent `
� deu'are that:
• l hzve 2ad ;his aoplicsocn and ail informadon suCni;.ed � he bcard;
• afl informaticn is ave, a�ra:e and comple;e;
• all ocher racuimd in(ormadon ras 5een h:1.7 cisdoseC;
• I am � e only Garnbiing r,�ana5er et :he organizaccn;
• 1 wiil �mil'�ariza myseit wi:h �a Iaws ol h{�nnese� scvemir,g :zwh,:i sz^ibiing 2r.d n::es ct rie bcard a^d zgre=, �i licanse�. :c
ebide by �ose k-.ws and rv!es, in�'uding amen��ens ;o �em:
� a�y ctianges in zcp�ic; ocn inicrmaticn will be suor,ir.ed ;o tCe Scvd and focai unit of gcvemment wit�in �0 cays oi ;hs cc;r_e:
� An a�davit for Sar,:olirg .^;n;ger h;s been com;.lereC �rd a.^.2reC, and
• I vnderstand J:af `ailure ;o prcvice required iniermacen cr ;reviding talse .nlermaccn may result in ss cenia! or :zvcca:cn e: ^e
licen5e.
Signa;�re of Gamciing
�------
1 :�2:E
!;22{4�
Sero :ha c�mpleted zcplica�icn and a'r{ reeuired attac�ments to:
Gambiing Control Soard
Suite 300 S.
7711 Y✓. County Road 9
F.oseville, MN 55113
��26s
: -�— - -
L�zis Mirtrtesata I.awfuF GambLfng .
�r�Y. �,vs2� GambIing Manager Affidavit ��`���`�
(A[tach to chc Gambltng 4(anager Appllcatlon. Fonn L�212)
STATEOF tdinnPS�ra' ) AFFIDAVITOFQUALIFiCATION
) s.s. FOR GAM5lING MANAGER LICENSE
COUNlYOr' '�ennepin � ANDCANSENTSTATEMENT
(Pursuznt to Minnesota Statute 349.16 Subd. 2(e)
and Minnesota Rule 7861.00.30,Subp. 128(3))
I, Steven P. Tibbeets _ , underoath state that:
(type/print name)
1. 1 have never been convicted ot a felony.
2. I have not, within tive years, committed a viofation of law or board rule that resutted in the
revocatan ot a license issued by the Lawfui Gambiing CoMrol Board.
3. I have never been convicted ot a criminai violation involving iraud, (heft, tax evasion,
misrepresentation, or gambiing.
8. 4 have never been convicted of 2ssault, a criminal violation invoiving the use of a firearm,
or making terroristic threats.
5. I zm not an assistant gambiing man2ger fcr zny other organization.
6, I am not a gambling manager for 2ny other org2nfzation.
In addilion, I understand, 2gree and hereby irrevocabiy consent thst su8s and actions relating to the sub�eci
marier of the ariached gzmbiing manager license, or acis or omissions ansing irom such applicatio�, may
be commenced against my organiz2tiortand i will accept ihe service oi process for my org2nization in any
court o( cornpefent jurisdic�ion in Minnesota by service on (he Minnesofa Secretary of State of any summens,
process o� pleading authorized by ihe laws of Minnesota,
By signature of this documern, the undersigned author'�zes the Deparlment of Public Satety to conduct a
criminai background check or review and to share the resutts with the l2wiul Gambling Control Board.
Failure to provide required i�tormation os providing talse or misieading intormation may resuft in the deniaf
or revocation of the license.
Subseribed and sworn to before me this
'z- — 1 day ot J.atJ v/� 1 g �'�
'�.�-� �--� � � [t�
County
���� ���
Nolary Public�
IvSy commission expires `� � L� ' � �
CLAY D. AMUNDSON
NOTARY PUBL.Ki • MINNFSOT,�
HENHEPlN GOUNTY
My wrmY�kn cqtra aiP-Ba
j � % /� .��.�,lf
(Signature of applicant - gambiing manager)
C�urci of the Incarnation'
(N2me of organization)
00639
License number
Council File # Q�
ordinance #
f;r �f�£t E {t, P
i P f ;i. .
li t�. [.., t Z'•, . i.�..
Fresented
Referred To
Committee: Date
35
RESOLVED: That application, ID �44765, for a Gamblinq Manager's License by Steven P.
Tibbetts DBA Church of the Zncarnation at the New Frontier Saloon, 230 Front
Avenue, be and the same is hereby approved.
Requested by Department of:
Office of License, Insnections and
Environmental Protection
BY: � ' ,, �k43�
Adoption Certified by Council Secretary
$Y� � t� �- . ��v�2�1 �
Approved by Mayor: Date U�5 4
Sy: �
Green Sheet $ 37921
RESOLUTION
CITY OF SAtNT PAllL, MINNESOTA
Form Approv d by C�ty torn
By: t�^��
Approved b ayor for Submission to
Council
By:
Adopted by Council: Date � . �y ��q*j
i GREEN SHEET
- 266-9132
7 O DEPARTMENT DIRECTOR
FON OCITYATTORNEY
� BUOGET �IRECTOR
� � MAVOR (Ofl ASSISTANT)
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
� -1 \
37�2�
MITIAWATE
� cm courvca
� C�TV CLERK
O FIN & MGT. SERYICES OIR.
�
Steven P. Tibbetts DBA Ghurch of the Incarnation requests Gouncil approval of
his application for a Gambling Manager's License, ID 4k44765, at the New Frontier Saloon,
230 Front Avenue.
Approve (A) or Re)ect
_ PLANNING COMMISSION __ CNft
_ CIB COMMI7TEE _ _
_ STAFF _ _
_ DISTRICT GOURT
SUPPORTS WHICH GOUNCIL O&IEC,TIVE?
Where,
PERSONAL SERYICE CONTRACT$ MUST ANSWER 7XE FOLLOWING QUESTIONS:
1 Has tdis personftirm ever worked u(Wer a contract fw this department?
YES NO
2. Has ihis persoNFirm ever been a ciry employee?
YES NO
9. Does this person/firm possess a skill not normally possessetl by any curreM city employeel
YES NO
Expletn 01! yes enswers on separete shcet anC ettach to green sheet
tOTAL AMOUN7 OF TRANSAC710N $
COS7/REVENUE BUDGETED (CIRCLE ONE) VES
NO
°UNDIfiG SOURCE ACTIVI7Y
'INANCIAL INFOFhiATION: (E%PLAIN)
�ae�. � v9zy
Minnesota LmUfuI Camb(ing
Gambling Manager Application
ase uc r
ScQ Y
FEE
GriK '
O�TE
INIT
,..,,.. -,...„ .. ..- ,, - - "�- - --. _ .. �
... -�,..;--_ �: ----:
r�e ��Appticatiort ' '
❑ New
� Rer.ev+al
` � 1 Ti 4"i
LAST NAME
Tibbetts
Give c'ats riat �e Nro-Cay 5�bting mana;er seminaz was completed. /_!_
lacadon of baining
(Gry)
11`q
Give Ca� of 72ining received wichin �`ree years pricr to �e �:e ot �e applicaoon lor renevral. 2 120 t 90
Lxa�onc(�alning W��-�=�r �'?i::nesoCa
..._...:...._. . .. . _ ... . . _ .. ... . .. . (c .... .. ..:......... ..... : •
lTiQ 27'�772 0T77tRiTOR . . . - . .
fiRST NAfdE MIDDLE NAME MAIDEN Oate o( Binh Sx.�Sec,vnry N�rber
✓
Steven ?atric�c 3J17/51 476-62=�869
G633 !,th ave. So. `ti: neapolls t�' Sa�'+0
MEMcEnSHIP: Date gamblirg mznaser'�ec�oe a memSer cf he organi:auon 2/ 17 / 79
�
Name ol CrSanizaicn
Church uf tia lr.c2r�2ticn
Adcress G�cfiSa:a Zip Code
3S1 � P� 2 25E7C .iV2. SO. .^.e:E�7D� i S �N �:.09
� �61� 3?"•-=�3�
Sex : ��.1 Mda ! remale
-:s::..
�ICEnSd N�1710Bf
:06 i°
F`one
�612 � $2?_
.... ...:.,..,.......:.� ..:...........:..::... .
:;:,. . .. .. .. ...:... ....."�
.. ..
`�QB� �af1.S�J� ' :. r;
-� A 510,W0 Gde4iy bond in favcr of ;he crc,anizaocn nutt be cbaine0 lor �e yamcfng manager.
Name of (nsurance campar.y (do nct use agenc� rsme� G S °icei-tv S Gu&r�nt3ond `umDer �-�'?0 �D-;vi0�^02-�
�AcJcnouiie�igr�ent `
� deu'are that:
• l hzve 2ad ;his aoplicsocn and ail informadon suCni;.ed � he bcard;
• afl informaticn is ave, a�ra:e and comple;e;
• all ocher racuimd in(ormadon ras 5een h:1.7 cisdoseC;
• I am � e only Garnbiing r,�ana5er et :he organizaccn;
• 1 wiil �mil'�ariza myseit wi:h �a Iaws ol h{�nnese� scvemir,g :zwh,:i sz^ibiing 2r.d n::es ct rie bcard a^d zgre=, �i licanse�. :c
ebide by �ose k-.ws and rv!es, in�'uding amen��ens ;o �em:
� a�y ctianges in zcp�ic; ocn inicrmaticn will be suor,ir.ed ;o tCe Scvd and focai unit of gcvemment wit�in �0 cays oi ;hs cc;r_e:
� An a�davit for Sar,:olirg .^;n;ger h;s been com;.lereC �rd a.^.2reC, and
• I vnderstand J:af `ailure ;o prcvice required iniermacen cr ;reviding talse .nlermaccn may result in ss cenia! or :zvcca:cn e: ^e
licen5e.
Signa;�re of Gamciing
�------
1 :�2:E
!;22{4�
Sero :ha c�mpleted zcplica�icn and a'r{ reeuired attac�ments to:
Gambiing Control Soard
Suite 300 S.
7711 Y✓. County Road 9
F.oseville, MN 55113
��26s
: -�— - -
L�zis Mirtrtesata I.awfuF GambLfng .
�r�Y. �,vs2� GambIing Manager Affidavit ��`���`�
(A[tach to chc Gambltng 4(anager Appllcatlon. Fonn L�212)
STATEOF tdinnPS�ra' ) AFFIDAVITOFQUALIFiCATION
) s.s. FOR GAM5lING MANAGER LICENSE
COUNlYOr' '�ennepin � ANDCANSENTSTATEMENT
(Pursuznt to Minnesota Statute 349.16 Subd. 2(e)
and Minnesota Rule 7861.00.30,Subp. 128(3))
I, Steven P. Tibbeets _ , underoath state that:
(type/print name)
1. 1 have never been convicted ot a felony.
2. I have not, within tive years, committed a viofation of law or board rule that resutted in the
revocatan ot a license issued by the Lawfui Gambiing CoMrol Board.
3. I have never been convicted ot a criminai violation involving iraud, (heft, tax evasion,
misrepresentation, or gambiing.
8. 4 have never been convicted of 2ssault, a criminal violation invoiving the use of a firearm,
or making terroristic threats.
5. I zm not an assistant gambiing man2ger fcr zny other organization.
6, I am not a gambling manager for 2ny other org2nfzation.
In addilion, I understand, 2gree and hereby irrevocabiy consent thst su8s and actions relating to the sub�eci
marier of the ariached gzmbiing manager license, or acis or omissions ansing irom such applicatio�, may
be commenced against my organiz2tiortand i will accept ihe service oi process for my org2nization in any
court o( cornpefent jurisdic�ion in Minnesota by service on (he Minnesofa Secretary of State of any summens,
process o� pleading authorized by ihe laws of Minnesota,
By signature of this documern, the undersigned author'�zes the Deparlment of Public Satety to conduct a
criminai background check or review and to share the resutts with the l2wiul Gambling Control Board.
Failure to provide required i�tormation os providing talse or misieading intormation may resuft in the deniaf
or revocation of the license.
Subseribed and sworn to before me this
'z- — 1 day ot J.atJ v/� 1 g �'�
'�.�-� �--� � � [t�
County
���� ���
Nolary Public�
IvSy commission expires `� � L� ' � �
CLAY D. AMUNDSON
NOTARY PUBL.Ki • MINNFSOT,�
HENHEPlN GOUNTY
My wrmY�kn cqtra aiP-Ba
j � % /� .��.�,lf
(Signature of applicant - gambiing manager)
C�urci of the Incarnation'
(N2me of organization)
00639
License number
Council File # Q�
ordinance #
f;r �f�£t E {t, P
i P f ;i. .
li t�. [.., t Z'•, . i.�..
Fresented
Referred To
Committee: Date
35
RESOLVED: That application, ID �44765, for a Gamblinq Manager's License by Steven P.
Tibbetts DBA Church of the Zncarnation at the New Frontier Saloon, 230 Front
Avenue, be and the same is hereby approved.
Requested by Department of:
Office of License, Insnections and
Environmental Protection
BY: � ' ,, �k43�
Adoption Certified by Council Secretary
$Y� � t� �- . ��v�2�1 �
Approved by Mayor: Date U�5 4
Sy: �
Green Sheet $ 37921
RESOLUTION
CITY OF SAtNT PAllL, MINNESOTA
Form Approv d by C�ty torn
By: t�^��
Approved b ayor for Submission to
Council
By:
Adopted by Council: Date � . �y ��q*j
i GREEN SHEET
- 266-9132
7 O DEPARTMENT DIRECTOR
FON OCITYATTORNEY
� BUOGET �IRECTOR
� � MAVOR (Ofl ASSISTANT)
TOTAL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS FOR SIGNATURE)
� -1 \
37�2�
MITIAWATE
� cm courvca
� C�TV CLERK
O FIN & MGT. SERYICES OIR.
�
Steven P. Tibbetts DBA Ghurch of the Incarnation requests Gouncil approval of
his application for a Gambling Manager's License, ID 4k44765, at the New Frontier Saloon,
230 Front Avenue.
Approve (A) or Re)ect
_ PLANNING COMMISSION __ CNft
_ CIB COMMI7TEE _ _
_ STAFF _ _
_ DISTRICT GOURT
SUPPORTS WHICH GOUNCIL O&IEC,TIVE?
Where,
PERSONAL SERYICE CONTRACT$ MUST ANSWER 7XE FOLLOWING QUESTIONS:
1 Has tdis personftirm ever worked u(Wer a contract fw this department?
YES NO
2. Has ihis persoNFirm ever been a ciry employee?
YES NO
9. Does this person/firm possess a skill not normally possessetl by any curreM city employeel
YES NO
Expletn 01! yes enswers on separete shcet anC ettach to green sheet
tOTAL AMOUN7 OF TRANSAC710N $
COS7/REVENUE BUDGETED (CIRCLE ONE) VES
NO
°UNDIfiG SOURCE ACTIVI7Y
'INANCIAL INFOFhiATION: (E%PLAIN)
�ae�. � v9zy
Minnesota LmUfuI Camb(ing
Gambling Manager Application
ase uc r
ScQ Y
FEE
GriK '
O�TE
INIT
,..,,.. -,...„ .. ..- ,, - - "�- - --. _ .. �
... -�,..;--_ �: ----:
r�e ��Appticatiort ' '
❑ New
� Rer.ev+al
` � 1 Ti 4"i
LAST NAME
Tibbetts
Give c'ats riat �e Nro-Cay 5�bting mana;er seminaz was completed. /_!_
lacadon of baining
(Gry)
11`q
Give Ca� of 72ining received wichin �`ree years pricr to �e �:e ot �e applicaoon lor renevral. 2 120 t 90
Lxa�onc(�alning W��-�=�r �'?i::nesoCa
..._...:...._. . .. . _ ... . . _ .. ... . .. . (c .... .. ..:......... ..... : •
lTiQ 27'�772 0T77tRiTOR . . . - . .
fiRST NAfdE MIDDLE NAME MAIDEN Oate o( Binh Sx.�Sec,vnry N�rber
✓
Steven ?atric�c 3J17/51 476-62=�869
G633 !,th ave. So. `ti: neapolls t�' Sa�'+0
MEMcEnSHIP: Date gamblirg mznaser'�ec�oe a memSer cf he organi:auon 2/ 17 / 79
�
Name ol CrSanizaicn
Church uf tia lr.c2r�2ticn
Adcress G�cfiSa:a Zip Code
3S1 � P� 2 25E7C .iV2. SO. .^.e:E�7D� i S �N �:.09
� �61� 3?"•-=�3�
Sex : ��.1 Mda ! remale
-:s::..
�ICEnSd N�1710Bf
:06 i°
F`one
�612 � $2?_
.... ...:.,..,.......:.� ..:...........:..::... .
:;:,. . .. .. .. ...:... ....."�
.. ..
`�QB� �af1.S�J� ' :. r;
-� A 510,W0 Gde4iy bond in favcr of ;he crc,anizaocn nutt be cbaine0 lor �e yamcfng manager.
Name of (nsurance campar.y (do nct use agenc� rsme� G S °icei-tv S Gu&r�nt3ond `umDer �-�'?0 �D-;vi0�^02-�
�AcJcnouiie�igr�ent `
� deu'are that:
• l hzve 2ad ;his aoplicsocn and ail informadon suCni;.ed � he bcard;
• afl informaticn is ave, a�ra:e and comple;e;
• all ocher racuimd in(ormadon ras 5een h:1.7 cisdoseC;
• I am � e only Garnbiing r,�ana5er et :he organizaccn;
• 1 wiil �mil'�ariza myseit wi:h �a Iaws ol h{�nnese� scvemir,g :zwh,:i sz^ibiing 2r.d n::es ct rie bcard a^d zgre=, �i licanse�. :c
ebide by �ose k-.ws and rv!es, in�'uding amen��ens ;o �em:
� a�y ctianges in zcp�ic; ocn inicrmaticn will be suor,ir.ed ;o tCe Scvd and focai unit of gcvemment wit�in �0 cays oi ;hs cc;r_e:
� An a�davit for Sar,:olirg .^;n;ger h;s been com;.lereC �rd a.^.2reC, and
• I vnderstand J:af `ailure ;o prcvice required iniermacen cr ;reviding talse .nlermaccn may result in ss cenia! or :zvcca:cn e: ^e
licen5e.
Signa;�re of Gamciing
�------
1 :�2:E
!;22{4�
Sero :ha c�mpleted zcplica�icn and a'r{ reeuired attac�ments to:
Gambiing Control Soard
Suite 300 S.
7711 Y✓. County Road 9
F.oseville, MN 55113
��26s
: -�— - -
L�zis Mirtrtesata I.awfuF GambLfng .
�r�Y. �,vs2� GambIing Manager Affidavit ��`���`�
(A[tach to chc Gambltng 4(anager Appllcatlon. Fonn L�212)
STATEOF tdinnPS�ra' ) AFFIDAVITOFQUALIFiCATION
) s.s. FOR GAM5lING MANAGER LICENSE
COUNlYOr' '�ennepin � ANDCANSENTSTATEMENT
(Pursuznt to Minnesota Statute 349.16 Subd. 2(e)
and Minnesota Rule 7861.00.30,Subp. 128(3))
I, Steven P. Tibbeets _ , underoath state that:
(type/print name)
1. 1 have never been convicted ot a felony.
2. I have not, within tive years, committed a viofation of law or board rule that resutted in the
revocatan ot a license issued by the Lawfui Gambiing CoMrol Board.
3. I have never been convicted ot a criminai violation involving iraud, (heft, tax evasion,
misrepresentation, or gambiing.
8. 4 have never been convicted of 2ssault, a criminal violation invoiving the use of a firearm,
or making terroristic threats.
5. I zm not an assistant gambiing man2ger fcr zny other organization.
6, I am not a gambling manager for 2ny other org2nfzation.
In addilion, I understand, 2gree and hereby irrevocabiy consent thst su8s and actions relating to the sub�eci
marier of the ariached gzmbiing manager license, or acis or omissions ansing irom such applicatio�, may
be commenced against my organiz2tiortand i will accept ihe service oi process for my org2nization in any
court o( cornpefent jurisdic�ion in Minnesota by service on (he Minnesofa Secretary of State of any summens,
process o� pleading authorized by ihe laws of Minnesota,
By signature of this documern, the undersigned author'�zes the Deparlment of Public Satety to conduct a
criminai background check or review and to share the resutts with the l2wiul Gambling Control Board.
Failure to provide required i�tormation os providing talse or misieading intormation may resuft in the deniaf
or revocation of the license.
Subseribed and sworn to before me this
'z- — 1 day ot J.atJ v/� 1 g �'�
'�.�-� �--� � � [t�
County
���� ���
Nolary Public�
IvSy commission expires `� � L� ' � �
CLAY D. AMUNDSON
NOTARY PUBL.Ki • MINNFSOT,�
HENHEPlN GOUNTY
My wrmY�kn cqtra aiP-Ba
j � % /� .��.�,lf
(Signature of applicant - gambiing manager)
C�urci of the Incarnation'
(N2me of organization)
00639
License number