97-1172Council File � \� ^��� e1+
ordinance #
Green Sheet # 37925
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r,���� F �
L% F"t i , f�'4 i
Presented By
Referred To
Committee: Date
:
RESOLVED: That applic�t�i,pp�ID #28788, for a Gambling Manager•s License by Valerie
Goodman DBA Region IZ Golden Gloves, Inc. at The ManorjCasey's, 2550 W. 7th
Street, be and the same is hereby approved.
Requested by Department of:
OEf'ce of License Inspections and
Environmental Proteotion
By: W.LCY�a::. �3�1� - - -
Form ��ed by City I f ep
BY � ° !� � rn+/�
Adoption Certified by Council Secretary � Approved by Mayor for Submission to
� � Council
$Y� ca-- ,
Ee�'��4 By �
Approved by Mayor: Date �
By: � �
RESOLUTION
41NT PAUL, MiNNESOTA
Adopted by Council: Date � �.y \°���
—� �
tizEr
TOTAL # OF SIGNATURE PAGES
° � 1 -\\r1�
GREEN SHEET 3?925
IN771AL/DATE It01TIAVDATE
DEPAkTMENiDIRECTOR �CfTYCOUNCII �
G1TY ATTORNEY O CIT' CLERK
BUDGET DIRECTOR O FIN. & MGT. SEflVICES DIR.
MAYOR (OR ASSISTANn �
(CLIP ALL LOCATIONS FOR SIGNATUflE)
Valerie Goodman DBA Region II Golden Gloves Assoc. requests Council approval
of her application for a Gambling Manager's License,(ID �k287S8), at The ManorJCasey's,
25 50 W. 7th Street.
Approve (A) or Rejeet (R)
__ PUWNINGCAMMISSION _ CIVIISEflY10ECOMMISSION
__ CIB COMMITTEE _
_ STAFf _
_ DISTqICTCOUFT _
SUPPORTS WHICH CWNCiI OBJEGi1YE?
IFAPPROVED:
DISADVANTAGES IF NOTAPPROVED
PERSONAL SERVICE CONTRACiS MUS7 ANSWEfl THE FOLLOWING �UES710NS:
1. Has this personflirm ever worked under a conVaCt for this department2
YES NO
2. Has ihis personflirm ever been a ciiy employee?
YES NO
3. Does this personrf�rm possess a skill �ot normally possessetl hy a�y current ciry employea?
YES NO
Explatn all yes answers on separate sheet and attaeh to green sheet
= �?�F&f;��
; }. y �;. r._ . -
�,��; � � 1��$
'OTAL AMOUNT OF TRANSAC710N $
COST/REVENUE BUDGETED (CIRCLE ONE)
YES NO
'UNDIfeG SOURCE ACTIVITY NUMBER
INANCIAL INfOR1.�ATION. (EXPLAIN)
":�.inesota Lczwful Gczmbling
Gambling Manager Application
�, `„�.��3
n`� �
:�=� � i
� .`��7
incompfete, false, or misleading app6cation information may resuit in denial of a license.
Organization fnformation �,,;� ;
OrganizationName ' � - � rG _ _' e� ci. ° ;; ��
CEOName 1'� ' - - �
(Cannot begamaling manager)
DaytimePhone( ' 1 �- � �' .�Qrganaatiort6aseLicenseNo. �• .� � � .�`�� �
Gambiin� Manager Information
Firsf Name ' ��- Full Middle Name �`
Maiden Name ' _ _ _ Date of &rth�_/�_! .��
SodatSecurityNumber ` =� �'- `---� � =� � � � �" _, _-
HomeStreetAddress -' �' %� '� '`
, ,
f:{iv � , �',•, . c,�sa
DaytimePhoneNUmber( 1 �� y" � - �
l became an active member of this organizatian on: /=
t attended the two-day gambliag manager seminar on: !_
Disc{osure of
Social Security Number
You a�e mquired to provide your sociai secu-
riry number on this form. Your soaaf secu-
rity number will be used to determine your
compliance with the tax laws of Minnesota.
Aufhonzation far requinng yoor soaal secu-
rity number is found at 42 U.S. C. 405(c)(i)
BOtt� 111fdCCila�lOi1 A 510,OOQ fidelity bond in favor of the organizatidn has been obta+ned
hy Minnesota Statutes, section 349.167, subdivision 1. _�
lnsurance Gompany Name: Bond Number.
(OQ NOT llSE THE AGENCY NAME)
Gamb[ing Manager Change
Emergency Ghange - auow up to rve days tor
processing
The chief executive o�cer, by signing below, affirms
that the emergency application is due to the foliowing
reason {check one and fill in date):
� Death otgambiing manager on �!_1
❑ pisatrility of gambiing manager on t !
!1t't erminaiion of employment of garnbling manager on
_...._����
NOTE: The new gambling manager may �ot assume
duties untit he/she has received the gambling manager's
license from the Gambling Controi Board.
its gambling manager,
Uttlef Gt7at1g2 - Atlow up to ten weeks for processing
The new gambiing manager's iicense shou4d become
effective (check one):
❑ The day after th= current g=mb!i^g marager's licens_
expires (for example, ifthe current gambfing manager's
license expires 7/31/96, the new gambling manager's
license becomes effective on 8/1l96, provided that ail
appGcation informatlon is compiete�.
� When the application has been processed by the Gam-
bling Control Board--the effective date wdl tre the first
day of the monih.
NOTE: The new gambling manager may not assume
duties until hefshe has received a gambling manager's
license from the Gambling Control Board.
Notary Public Information. Notary Public 8ea! must
be current and correct; seal may not be altered.
Subscrib d and sworn to before me this 3��3 day
of �AY�,�-� � , 19
�, �
�
,., ., �
r � '� ��SGOTf
�;,,•;:��..,-�+ �)C'l� tft30�
Board
: Lic #
°l'1-t�� a�
LG212
8/96
Page 1 of 2
�
� LastName r.;�.�� ,7°�: �;
Checkoneoftheboxes. � Mal> `�,Female
�;�\
�' \
, l�
��
Ty (continued on b ( � a ' � c y k p ) � __
3i.��J �,�./ � 1=_!�Y! ��
Gambling Manager Application (continned)
Affidavit and Cansent Statement:
�,
I, (pnni name) � +� � _ - _
under oath state that t have never:
l. been conv�cted cf a felony or a crime i�voiving gam-
bfing;
2. committed a violation of law or Board rule that resulted
in the revocation of a Iicense issued by the Board within
five years bafore the date of the ficense application;
3. been convicted of a criminaf violation invofving fraud,
theft. fax evasion, m+srepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving the use of a firearm, or (iii) making terroristic
threats.
5. been connected with nor engaged in an iAegal busi-
ness:
6. owed 5500 or more in delinquent taxes as defined itt
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8, tai4ed ta fi{e, after demand, tax retums required by the
cQmmission8r of reve�ue.
in addition, I understand, agree, and hereby irrevocabiy
consent that suits and actions relating to the subject mat-
ter of the attaehed gamb{ing manager license application,
or acts oromissions arising from such application, may be
commenced against me or my organization and I wili
accep4 the serviee of process in any court of coropetent
jurisdietimn in Mi�nesota by seroice oR the Minnesota
Secretary of State of any summons, process, or pieading
authorizzd by the faws of Minnesota.
By signature af this document, the undersigned authorizes
the OepaRments of Public Safety and Revenue to con-
duct a criminal and iax background check or review and
!o sh2re the *esults wi?h the Gambiing Control Soard.
�ailure ta provide required information or providing false
or misleading informatron may result in the denial or
revocation of the iicense.
FURTHER AFFfANT SAYETH NOT, except that this
Affidavit and Consent Statement are submitted in support
of the applicatlon for a gambling manager Ucense from
the Gambfing Contral Board.
Signature of Gambfing Manager
Appticant ;
{i. '�- �--,/<� /
NotanzedSigna:ure Q(Applic3nt
l ``../ �_� u� `" LG212
8J96
Par� "L of Z
This pubiication wiff be made availabie in aiternative
format (i.e. large print, Braille) upon request. If you
�se a ITY, you can call us using the Minnesota Relay
Service ai 1-800-627-3529 and ask them to piace a
call to (612) 639-40�0.
The information requested on this form will be used
by the Gambling Control Board (Boardj to determine
your compliance with Minnesota statutes and ruies
governing lawfui gambling activities. All of the infor-
mation that you supply on this form wili become
pubfic information when received by the Boasd.
The information requested on this form (including any
attachments) wiU be used by the Board to determine
your qualifica:ions to be invofved in iawful gambbng
activities in Minnesota, and to assist the Board m
conducting a background investigation of you.
You have the right to refuse to supply the information
requested; however, if you refuse to supply this infor-
mation, the Soard may not be able to determine your
qualifications and, as a consequence, may refuse to
issue you a license. If you supply the information
required, the Board wili be abiQ to process your appii-
cation.
Your name and address will be public information when
received by the Soard. All the other information about
you that you provide wilf be private data until the Soard
issues your license. When the 8oard issues yQUr
license, ail of the information you have provided to
the Board in the prncess of appfying for your Dcense
wiU become public except for your sociai secunty num-
ber, which remains private.
If the Board does not issue you a license, all the infor-
mation you have provided in the process of appiying
for a license remains private, with the except�on of
your name and addres5, which wili remain publlc.
Private data about you is ava'tlable on4y to the follow-
ing: Board members, staff of the Board whose work
assig�me�t requires that they have access to the
information; the Minnesota Department of Public
Satety; the Minnesota Attomey General; the Minne-
sota Ccmmissioners cf Administrahon, Firance, ar.�
Ravenue; the Legistative Auditor, narional and inter-
nat+onal gambling reguiatory agencies; anyone pur-
suant to court order; other individuals and agencies
that may be specifically authorized by state or federal
law to have access to such information; individuals
and agencies for which law or legal order authorizes a
new use or sharing of the information after this notice
is given; you; and anyone with your written consent.
Notary Public information. Notary Pub��c Sea1 must
be current and correct seal may not be �e�e��+
Subscrf ed and sworn to before me this � day
of �' ,� , 19 %� _
iTE r �-+'1i�et
NDTARYFUi��„•;...._ i
SCOTT COUiJ"i'�- ���?j
'�Y ��Tn Frpims L:�i i i .y:� �
�LKk4±.++. «._._... .
1 ��ti1�
Council File � \� ^��� e1+
ordinance #
Green Sheet # 37925
1
2
3
4
5
6
7
S
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
r,���� F �
L% F"t i , f�'4 i
Presented By
Referred To
Committee: Date
:
RESOLVED: That applic�t�i,pp�ID #28788, for a Gambling Manager•s License by Valerie
Goodman DBA Region IZ Golden Gloves, Inc. at The ManorjCasey's, 2550 W. 7th
Street, be and the same is hereby approved.
Requested by Department of:
OEf'ce of License Inspections and
Environmental Proteotion
By: W.LCY�a::. �3�1� - - -
Form ��ed by City I f ep
BY � ° !� � rn+/�
Adoption Certified by Council Secretary � Approved by Mayor for Submission to
� � Council
$Y� ca-- ,
Ee�'��4 By �
Approved by Mayor: Date �
By: � �
RESOLUTION
41NT PAUL, MiNNESOTA
Adopted by Council: Date � �.y \°���
—� �
tizEr
TOTAL # OF SIGNATURE PAGES
° � 1 -\\r1�
GREEN SHEET 3?925
IN771AL/DATE It01TIAVDATE
DEPAkTMENiDIRECTOR �CfTYCOUNCII �
G1TY ATTORNEY O CIT' CLERK
BUDGET DIRECTOR O FIN. & MGT. SEflVICES DIR.
MAYOR (OR ASSISTANn �
(CLIP ALL LOCATIONS FOR SIGNATUflE)
Valerie Goodman DBA Region II Golden Gloves Assoc. requests Council approval
of her application for a Gambling Manager's License,(ID �k287S8), at The ManorJCasey's,
25 50 W. 7th Street.
Approve (A) or Rejeet (R)
__ PUWNINGCAMMISSION _ CIVIISEflY10ECOMMISSION
__ CIB COMMITTEE _
_ STAFf _
_ DISTqICTCOUFT _
SUPPORTS WHICH CWNCiI OBJEGi1YE?
IFAPPROVED:
DISADVANTAGES IF NOTAPPROVED
PERSONAL SERVICE CONTRACiS MUS7 ANSWEfl THE FOLLOWING �UES710NS:
1. Has this personflirm ever worked under a conVaCt for this department2
YES NO
2. Has ihis personflirm ever been a ciiy employee?
YES NO
3. Does this personrf�rm possess a skill �ot normally possessetl hy a�y current ciry employea?
YES NO
Explatn all yes answers on separate sheet and attaeh to green sheet
= �?�F&f;��
; }. y �;. r._ . -
�,��; � � 1��$
'OTAL AMOUNT OF TRANSAC710N $
COST/REVENUE BUDGETED (CIRCLE ONE)
YES NO
'UNDIfeG SOURCE ACTIVITY NUMBER
INANCIAL INfOR1.�ATION. (EXPLAIN)
":�.inesota Lczwful Gczmbling
Gambling Manager Application
�, `„�.��3
n`� �
:�=� � i
� .`��7
incompfete, false, or misleading app6cation information may resuit in denial of a license.
Organization fnformation �,,;� ;
OrganizationName ' � - � rG _ _' e� ci. ° ;; ��
CEOName 1'� ' - - �
(Cannot begamaling manager)
DaytimePhone( ' 1 �- � �' .�Qrganaatiort6aseLicenseNo. �• .� � � .�`�� �
Gambiin� Manager Information
Firsf Name ' ��- Full Middle Name �`
Maiden Name ' _ _ _ Date of &rth�_/�_! .��
SodatSecurityNumber ` =� �'- `---� � =� � � � �" _, _-
HomeStreetAddress -' �' %� '� '`
, ,
f:{iv � , �',•, . c,�sa
DaytimePhoneNUmber( 1 �� y" � - �
l became an active member of this organizatian on: /=
t attended the two-day gambliag manager seminar on: !_
Disc{osure of
Social Security Number
You a�e mquired to provide your sociai secu-
riry number on this form. Your soaaf secu-
rity number will be used to determine your
compliance with the tax laws of Minnesota.
Aufhonzation far requinng yoor soaal secu-
rity number is found at 42 U.S. C. 405(c)(i)
BOtt� 111fdCCila�lOi1 A 510,OOQ fidelity bond in favor of the organizatidn has been obta+ned
hy Minnesota Statutes, section 349.167, subdivision 1. _�
lnsurance Gompany Name: Bond Number.
(OQ NOT llSE THE AGENCY NAME)
Gamb[ing Manager Change
Emergency Ghange - auow up to rve days tor
processing
The chief executive o�cer, by signing below, affirms
that the emergency application is due to the foliowing
reason {check one and fill in date):
� Death otgambiing manager on �!_1
❑ pisatrility of gambiing manager on t !
!1t't erminaiion of employment of garnbling manager on
_...._����
NOTE: The new gambling manager may �ot assume
duties untit he/she has received the gambling manager's
license from the Gambling Controi Board.
its gambling manager,
Uttlef Gt7at1g2 - Atlow up to ten weeks for processing
The new gambiing manager's iicense shou4d become
effective (check one):
❑ The day after th= current g=mb!i^g marager's licens_
expires (for example, ifthe current gambfing manager's
license expires 7/31/96, the new gambling manager's
license becomes effective on 8/1l96, provided that ail
appGcation informatlon is compiete�.
� When the application has been processed by the Gam-
bling Control Board--the effective date wdl tre the first
day of the monih.
NOTE: The new gambling manager may not assume
duties until hefshe has received a gambling manager's
license from the Gambling Control Board.
Notary Public Information. Notary Public 8ea! must
be current and correct; seal may not be altered.
Subscrib d and sworn to before me this 3��3 day
of �AY�,�-� � , 19
�, �
�
,., ., �
r � '� ��SGOTf
�;,,•;:��..,-�+ �)C'l� tft30�
Board
: Lic #
°l'1-t�� a�
LG212
8/96
Page 1 of 2
�
� LastName r.;�.�� ,7°�: �;
Checkoneoftheboxes. � Mal> `�,Female
�;�\
�' \
, l�
��
Ty (continued on b ( � a ' � c y k p ) � __
3i.��J �,�./ � 1=_!�Y! ��
Gambling Manager Application (continned)
Affidavit and Cansent Statement:
�,
I, (pnni name) � +� � _ - _
under oath state that t have never:
l. been conv�cted cf a felony or a crime i�voiving gam-
bfing;
2. committed a violation of law or Board rule that resulted
in the revocation of a Iicense issued by the Board within
five years bafore the date of the ficense application;
3. been convicted of a criminaf violation invofving fraud,
theft. fax evasion, m+srepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving the use of a firearm, or (iii) making terroristic
threats.
5. been connected with nor engaged in an iAegal busi-
ness:
6. owed 5500 or more in delinquent taxes as defined itt
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8, tai4ed ta fi{e, after demand, tax retums required by the
cQmmission8r of reve�ue.
in addition, I understand, agree, and hereby irrevocabiy
consent that suits and actions relating to the subject mat-
ter of the attaehed gamb{ing manager license application,
or acts oromissions arising from such application, may be
commenced against me or my organization and I wili
accep4 the serviee of process in any court of coropetent
jurisdietimn in Mi�nesota by seroice oR the Minnesota
Secretary of State of any summons, process, or pieading
authorizzd by the faws of Minnesota.
By signature af this document, the undersigned authorizes
the OepaRments of Public Safety and Revenue to con-
duct a criminal and iax background check or review and
!o sh2re the *esults wi?h the Gambiing Control Soard.
�ailure ta provide required information or providing false
or misleading informatron may result in the denial or
revocation of the iicense.
FURTHER AFFfANT SAYETH NOT, except that this
Affidavit and Consent Statement are submitted in support
of the applicatlon for a gambling manager Ucense from
the Gambfing Contral Board.
Signature of Gambfing Manager
Appticant ;
{i. '�- �--,/<� /
NotanzedSigna:ure Q(Applic3nt
l ``../ �_� u� `" LG212
8J96
Par� "L of Z
This pubiication wiff be made availabie in aiternative
format (i.e. large print, Braille) upon request. If you
�se a ITY, you can call us using the Minnesota Relay
Service ai 1-800-627-3529 and ask them to piace a
call to (612) 639-40�0.
The information requested on this form will be used
by the Gambling Control Board (Boardj to determine
your compliance with Minnesota statutes and ruies
governing lawfui gambling activities. All of the infor-
mation that you supply on this form wili become
pubfic information when received by the Boasd.
The information requested on this form (including any
attachments) wiU be used by the Board to determine
your qualifica:ions to be invofved in iawful gambbng
activities in Minnesota, and to assist the Board m
conducting a background investigation of you.
You have the right to refuse to supply the information
requested; however, if you refuse to supply this infor-
mation, the Soard may not be able to determine your
qualifications and, as a consequence, may refuse to
issue you a license. If you supply the information
required, the Board wili be abiQ to process your appii-
cation.
Your name and address will be public information when
received by the Soard. All the other information about
you that you provide wilf be private data until the Soard
issues your license. When the 8oard issues yQUr
license, ail of the information you have provided to
the Board in the prncess of appfying for your Dcense
wiU become public except for your sociai secunty num-
ber, which remains private.
If the Board does not issue you a license, all the infor-
mation you have provided in the process of appiying
for a license remains private, with the except�on of
your name and addres5, which wili remain publlc.
Private data about you is ava'tlable on4y to the follow-
ing: Board members, staff of the Board whose work
assig�me�t requires that they have access to the
information; the Minnesota Department of Public
Satety; the Minnesota Attomey General; the Minne-
sota Ccmmissioners cf Administrahon, Firance, ar.�
Ravenue; the Legistative Auditor, narional and inter-
nat+onal gambling reguiatory agencies; anyone pur-
suant to court order; other individuals and agencies
that may be specifically authorized by state or federal
law to have access to such information; individuals
and agencies for which law or legal order authorizes a
new use or sharing of the information after this notice
is given; you; and anyone with your written consent.
Notary Public information. Notary Pub��c Sea1 must
be current and correct seal may not be �e�e��+
Subscrf ed and sworn to before me this � day
of �' ,� , 19 %� _
iTE r �-+'1i�et
NDTARYFUi��„•;...._ i
SCOTT COUiJ"i'�- ���?j
'�Y ��Tn Frpims L:�i i i .y:� �
�LKk4±.++. «._._... .
1 ��ti1�
Council File � \� ^��� e1+
ordinance #
Green Sheet # 37925
1
2
3
4
5
6
7
S
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
r,���� F �
L% F"t i , f�'4 i
Presented By
Referred To
Committee: Date
:
RESOLVED: That applic�t�i,pp�ID #28788, for a Gambling Manager•s License by Valerie
Goodman DBA Region IZ Golden Gloves, Inc. at The ManorjCasey's, 2550 W. 7th
Street, be and the same is hereby approved.
Requested by Department of:
OEf'ce of License Inspections and
Environmental Proteotion
By: W.LCY�a::. �3�1� - - -
Form ��ed by City I f ep
BY � ° !� � rn+/�
Adoption Certified by Council Secretary � Approved by Mayor for Submission to
� � Council
$Y� ca-- ,
Ee�'��4 By �
Approved by Mayor: Date �
By: � �
RESOLUTION
41NT PAUL, MiNNESOTA
Adopted by Council: Date � �.y \°���
—� �
tizEr
TOTAL # OF SIGNATURE PAGES
° � 1 -\\r1�
GREEN SHEET 3?925
IN771AL/DATE It01TIAVDATE
DEPAkTMENiDIRECTOR �CfTYCOUNCII �
G1TY ATTORNEY O CIT' CLERK
BUDGET DIRECTOR O FIN. & MGT. SEflVICES DIR.
MAYOR (OR ASSISTANn �
(CLIP ALL LOCATIONS FOR SIGNATUflE)
Valerie Goodman DBA Region II Golden Gloves Assoc. requests Council approval
of her application for a Gambling Manager's License,(ID �k287S8), at The ManorJCasey's,
25 50 W. 7th Street.
Approve (A) or Rejeet (R)
__ PUWNINGCAMMISSION _ CIVIISEflY10ECOMMISSION
__ CIB COMMITTEE _
_ STAFf _
_ DISTqICTCOUFT _
SUPPORTS WHICH CWNCiI OBJEGi1YE?
IFAPPROVED:
DISADVANTAGES IF NOTAPPROVED
PERSONAL SERVICE CONTRACiS MUS7 ANSWEfl THE FOLLOWING �UES710NS:
1. Has this personflirm ever worked under a conVaCt for this department2
YES NO
2. Has ihis personflirm ever been a ciiy employee?
YES NO
3. Does this personrf�rm possess a skill �ot normally possessetl hy a�y current ciry employea?
YES NO
Explatn all yes answers on separate sheet and attaeh to green sheet
= �?�F&f;��
; }. y �;. r._ . -
�,��; � � 1��$
'OTAL AMOUNT OF TRANSAC710N $
COST/REVENUE BUDGETED (CIRCLE ONE)
YES NO
'UNDIfeG SOURCE ACTIVITY NUMBER
INANCIAL INfOR1.�ATION. (EXPLAIN)
":�.inesota Lczwful Gczmbling
Gambling Manager Application
�, `„�.��3
n`� �
:�=� � i
� .`��7
incompfete, false, or misleading app6cation information may resuit in denial of a license.
Organization fnformation �,,;� ;
OrganizationName ' � - � rG _ _' e� ci. ° ;; ��
CEOName 1'� ' - - �
(Cannot begamaling manager)
DaytimePhone( ' 1 �- � �' .�Qrganaatiort6aseLicenseNo. �• .� � � .�`�� �
Gambiin� Manager Information
Firsf Name ' ��- Full Middle Name �`
Maiden Name ' _ _ _ Date of &rth�_/�_! .��
SodatSecurityNumber ` =� �'- `---� � =� � � � �" _, _-
HomeStreetAddress -' �' %� '� '`
, ,
f:{iv � , �',•, . c,�sa
DaytimePhoneNUmber( 1 �� y" � - �
l became an active member of this organizatian on: /=
t attended the two-day gambliag manager seminar on: !_
Disc{osure of
Social Security Number
You a�e mquired to provide your sociai secu-
riry number on this form. Your soaaf secu-
rity number will be used to determine your
compliance with the tax laws of Minnesota.
Aufhonzation far requinng yoor soaal secu-
rity number is found at 42 U.S. C. 405(c)(i)
BOtt� 111fdCCila�lOi1 A 510,OOQ fidelity bond in favor of the organizatidn has been obta+ned
hy Minnesota Statutes, section 349.167, subdivision 1. _�
lnsurance Gompany Name: Bond Number.
(OQ NOT llSE THE AGENCY NAME)
Gamb[ing Manager Change
Emergency Ghange - auow up to rve days tor
processing
The chief executive o�cer, by signing below, affirms
that the emergency application is due to the foliowing
reason {check one and fill in date):
� Death otgambiing manager on �!_1
❑ pisatrility of gambiing manager on t !
!1t't erminaiion of employment of garnbling manager on
_...._����
NOTE: The new gambling manager may �ot assume
duties untit he/she has received the gambling manager's
license from the Gambling Controi Board.
its gambling manager,
Uttlef Gt7at1g2 - Atlow up to ten weeks for processing
The new gambiing manager's iicense shou4d become
effective (check one):
❑ The day after th= current g=mb!i^g marager's licens_
expires (for example, ifthe current gambfing manager's
license expires 7/31/96, the new gambling manager's
license becomes effective on 8/1l96, provided that ail
appGcation informatlon is compiete�.
� When the application has been processed by the Gam-
bling Control Board--the effective date wdl tre the first
day of the monih.
NOTE: The new gambling manager may not assume
duties until hefshe has received a gambling manager's
license from the Gambling Control Board.
Notary Public Information. Notary Public 8ea! must
be current and correct; seal may not be altered.
Subscrib d and sworn to before me this 3��3 day
of �AY�,�-� � , 19
�, �
�
,., ., �
r � '� ��SGOTf
�;,,•;:��..,-�+ �)C'l� tft30�
Board
: Lic #
°l'1-t�� a�
LG212
8/96
Page 1 of 2
�
� LastName r.;�.�� ,7°�: �;
Checkoneoftheboxes. � Mal> `�,Female
�;�\
�' \
, l�
��
Ty (continued on b ( � a ' � c y k p ) � __
3i.��J �,�./ � 1=_!�Y! ��
Gambling Manager Application (continned)
Affidavit and Cansent Statement:
�,
I, (pnni name) � +� � _ - _
under oath state that t have never:
l. been conv�cted cf a felony or a crime i�voiving gam-
bfing;
2. committed a violation of law or Board rule that resulted
in the revocation of a Iicense issued by the Board within
five years bafore the date of the ficense application;
3. been convicted of a criminaf violation invofving fraud,
theft. fax evasion, m+srepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving the use of a firearm, or (iii) making terroristic
threats.
5. been connected with nor engaged in an iAegal busi-
ness:
6. owed 5500 or more in delinquent taxes as defined itt
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue within the past two years;
8, tai4ed ta fi{e, after demand, tax retums required by the
cQmmission8r of reve�ue.
in addition, I understand, agree, and hereby irrevocabiy
consent that suits and actions relating to the subject mat-
ter of the attaehed gamb{ing manager license application,
or acts oromissions arising from such application, may be
commenced against me or my organization and I wili
accep4 the serviee of process in any court of coropetent
jurisdietimn in Mi�nesota by seroice oR the Minnesota
Secretary of State of any summons, process, or pieading
authorizzd by the faws of Minnesota.
By signature af this document, the undersigned authorizes
the OepaRments of Public Safety and Revenue to con-
duct a criminal and iax background check or review and
!o sh2re the *esults wi?h the Gambiing Control Soard.
�ailure ta provide required information or providing false
or misleading informatron may result in the denial or
revocation of the iicense.
FURTHER AFFfANT SAYETH NOT, except that this
Affidavit and Consent Statement are submitted in support
of the applicatlon for a gambling manager Ucense from
the Gambfing Contral Board.
Signature of Gambfing Manager
Appticant ;
{i. '�- �--,/<� /
NotanzedSigna:ure Q(Applic3nt
l ``../ �_� u� `" LG212
8J96
Par� "L of Z
This pubiication wiff be made availabie in aiternative
format (i.e. large print, Braille) upon request. If you
�se a ITY, you can call us using the Minnesota Relay
Service ai 1-800-627-3529 and ask them to piace a
call to (612) 639-40�0.
The information requested on this form will be used
by the Gambling Control Board (Boardj to determine
your compliance with Minnesota statutes and ruies
governing lawfui gambling activities. All of the infor-
mation that you supply on this form wili become
pubfic information when received by the Boasd.
The information requested on this form (including any
attachments) wiU be used by the Board to determine
your qualifica:ions to be invofved in iawful gambbng
activities in Minnesota, and to assist the Board m
conducting a background investigation of you.
You have the right to refuse to supply the information
requested; however, if you refuse to supply this infor-
mation, the Soard may not be able to determine your
qualifications and, as a consequence, may refuse to
issue you a license. If you supply the information
required, the Board wili be abiQ to process your appii-
cation.
Your name and address will be public information when
received by the Soard. All the other information about
you that you provide wilf be private data until the Soard
issues your license. When the 8oard issues yQUr
license, ail of the information you have provided to
the Board in the prncess of appfying for your Dcense
wiU become public except for your sociai secunty num-
ber, which remains private.
If the Board does not issue you a license, all the infor-
mation you have provided in the process of appiying
for a license remains private, with the except�on of
your name and addres5, which wili remain publlc.
Private data about you is ava'tlable on4y to the follow-
ing: Board members, staff of the Board whose work
assig�me�t requires that they have access to the
information; the Minnesota Department of Public
Satety; the Minnesota Attomey General; the Minne-
sota Ccmmissioners cf Administrahon, Firance, ar.�
Ravenue; the Legistative Auditor, narional and inter-
nat+onal gambling reguiatory agencies; anyone pur-
suant to court order; other individuals and agencies
that may be specifically authorized by state or federal
law to have access to such information; individuals
and agencies for which law or legal order authorizes a
new use or sharing of the information after this notice
is given; you; and anyone with your written consent.
Notary Public information. Notary Pub��c Sea1 must
be current and correct seal may not be �e�e��+
Subscrf ed and sworn to before me this � day
of �' ,� , 19 %� _
iTE r �-+'1i�et
NDTARYFUi��„•;...._ i
SCOTT COUiJ"i'�- ���?j
'�Y ��Tn Frpims L:�i i i .y:� �
�LKk4±.++. «._._... .
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