97-1248Council File � 97— �e���
ordinance #
Green Sheet � 50228
1
2
3
4
5
6
7
8
9
10
11
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13
14
IS
16
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18
t9
',0
1
2
3
Presented By�
)���
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
3�
Committee: Date
RESOLVED: That application, ID �34005, for a Gambling Manager's License by Margaret
5t. Sauver DBA East Twins Babe Ruth League, Inc. at Paul's Lounge, 1045
Hudson Road, be and the same is hereby approved.
Requested by Department of:
• - - - - . .
• - .t
By: ��t�w � �
ldoption Certified by Council Secretary
1'' � .. �
� t c"-
pproved by Mayor: Date #al€�-l� Z
, � k��= ��
Form Approved by City At�ey
By:
Approved by yor £or Submission to
Council
By:
Adopted by Council: Date Q�,'�_ g\qQ�
�„'_'_�—
FOR
TOTAL # OF SIGNATURE PAGES
N° 5022�
l GREEN SHEE °� � -1a'�8'
INITIAL/OATE INITIALIOATE
DEPARTMENTDIRECTOR �CINCOUNCIL
CI7Y ATTORNEY O GTY CIERK
BUDGET OIRECiOH � PIN- 8 MOT SEflViCES OIR
MAYOR (OR ASSYSTANn �
(CLIP ALL LOCATIONS FOR SIGNATURE}
Margaret St. Sauver DBA East Twins Babe Ruth League, Inc. requests CounciZ
approval of her application for a Gambling Manager`s License, ID �/34005, at Paul's Lounge,
1045 Hudson Road.
NECOMMENDATONS; ApprWB (A) or Rejact (R)
__ FIANNIN6 CqMMISSfON _
__C18CQMM1TfEE _
__ STAFF _
__ DISTRICTCOVRT _ .
SUGPOATS WH�CH CAUNqI O&1ECTIVE?
what,
PERSONAL SERVfGE CONTRACTS MUST ANSWER THE FQItOW�NG QUESTIONS:
t Has Ynis persoMtirm ever worked untler a contract tor this tlepartment�
YES NO
2. Has this person/firm ever been a ciTy emplpyee?
YES NO
3. DoeS this personRirm po5sess a skili not normally passassetl by arry current ciry empioyee�
YES NO
Explaln ali yes anawers on aeparafe aheet antl attach to green sheet
�Y1.
)VANTAGES 1F APPPqVEO
Cit�}u,,�°j� n."`f?�.t'7� is�i§S'+
t� . '.�� N VS ����
�UNTOFTRANSACTION $
COSTIREYENUE BUDGE7E0 (ClRCLE ONE) YES NO
fURCE ACTIVITY NUMBER
�R6aAT10N� (EXPlA1N)
. 9 � � 13��1fr
East STATE OF MINXESOTA . FOR HOARD VSE ONLY
GAMSLZHG CONTROL BOARD AMT. PAID
GAMBLING MANRGEX LICENSE RENEWAL APPLZCATION CHECK #
LC212GMR PRINTED: 07f11f45 DATE
LZCENSE NUMBER: f3-Q1991 001 EFFECTIVE DATE: O1(O1J95 E%PZRATION DATE: 12f31/95
NAHE OF ORGRNZZATZON: Babe Rutb League St Faul East Twius
CiAMBLS126 MNIA6ER INFORMATIOH
Margaret Ana St Sauver
1� , � �7�� 3i'�Y S"
�* � , ` � c �'J'tA-C`Lf J' � 7
7
DAY2IME PHONE NUMBER: 612-7�6-2665
DATE OF BIRTH: 03/07/49
SEXS F
SOCIAL SECURITY NUMBERs 475-58-9?64
MEMSER SINCE: 04/29J86 �}
� J 7 �
LAST DATE YOU ATTENDED A GAMBLING MANAGER5.8EMINAR/CONTINUINQ EDUCATION CLASS: -�6f49�f-94
HOPID INFORMATION
SOND COMFANY NAN,E: Uaited States Fide13 BOND NUMBERs 20003011831926
ACKNOWLED(3MENT
DECLIIRE TftATt
I HAVE R$AD THI�S APPLZCATION AND ALL INFORMATION SUBMITTED TO Tf3E GAMBLING CONTROL BOARD;
ALL INFORMATION IS TRUE, ACCURATE ANR COMPLETE;
ALL OTHBR REqUiRED INFQRMATION HAS�BEEN FULLY DISCLOSED;
Z AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION�
I HAVE 6EEN AN ACTIVE MEMSER OF THE ORGANIZATION FOR AT LEAST TWO YEARS;
L WILL FAMILIARI2E MYSELF WITH THE LAWS OF MINNESOTA GOVERNiNG LAWFUL GAMBLING AND RULES OF
CHE GAMSLING CONTROL BOARA AND AGREE, IF LICENSED, TO AHTDE THOSE LAWS AND RULES,
'.NCLUDING AHEN�MENTS TO THEM�
NY CBANGES ZN APPLICATION IfiFORMATZON 4IILL BE SUSMZTTED 20 THE GAMSLZNG CONTROL BOARD AND
pCAL UNIT OF GOVERNMENT WITHIN 30 DAYS OF THE CHANGE)
V AFFZpAVZT FOR GAM&LING MANAGER HAS HEEN COMPLETED AND RTTACHED� AND
DNDERSTAN4 THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
tFORMATION MAY RESSILT IN THE DEN2AL OR REVOCATION OF THE LZCENSE.
ATURE OF ORMBLIN6 11ANA6ER DATE
REFER TO THE CHECRI.SST FOR REQUIRED ATTAC
MAIL TO: GRMALIN6 CONTROL BOAAD
1711 WEST COUNTY ROAD H, SUITE 3QOS
FOSEVILLE� MINNESOTA 55113
)RM WILL BE MADE AVAILASLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST
� �
LG213
04J18t95
Minnesota Gambling Controi Board
Gambling Manager Affidavit ��7„y�'
Attach to the Gambling Manager Apptication, Form tG2i2 �
�
STATE OF �� pn� 5� ��- 1 ) AFFIDAVIT OF QUALIFICATION
FOR GAMBLING MANAGER LICENSE
� S ' $ ' AND CONSENT S7ATEMENT
GOUNTY OF �, � ) (Pursuant to Minnesota Statutes and Rules)
�,1� I�cn, r_ t" �f ' i � a��� r— , Under oath state that:
( ype/print name)
t. I have never been convicted of a felony or a crime invoiving gambiing.
2. f have not, within five years before the date of the license application, committed a viofation of law or
Board rule that resulied in the revocation of a license issued by ihe 8oarti.
3. i have never been convicted of a criminai violation invo{ving fraud, thefl, tax evasion, misrepresentation,
or gambling.
4. I have neve� been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii)
making terroristic threats.
. �,
5. { am not, nor ever have been connected with or engaged in an illegal business.
6. i do noi owe $500 or more in delinquent taxes as defined in section 27d.72.
7. i have not had a saies and use tax permit revoked by the commissioner of revenue within the past two
year5:
8. I have never, after demand, failed to file tax retums required by the commissioner of revenue.
In addition, I u�derstand, agree and hereby irrevocabiy consent that suits and actions relating to the subject
marier of the attached gambling manager ficense application, or acts or omissions arising from such applica-
tion, may be commenced against my organization and I will accept the service of process for my organiza-
tion in any court of competent }�risdiction in Minnesota by service on the Minnesota Secretary of State af 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 conduct a
criminal background check or review and to share the resuits with the Gambling Controi Board.
=ailure to provide required intormation or providing false or misleading information may resuit in the deniai or
evocaiion of the license.
URTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in
�ppod of the appiication for a gambling manager license from the Gambling Co�trot Board.
NOTARY PUBLfC lNFORMRTION
Seal must be current and correct.
�al may not be altered.
ubscribed and swom to before me this
/.S��fday of `-�e �d fe,Uj j� e 12 19
�
R, SPIELMAh
/ ' // ��C.i.CX Y � � d. �L7�'"'Z�_
� � {signature of applicant)
ORGANIZAT/ON (NFORMAT(ON
of Organization
/�„ <
Council File � 97— �e���
ordinance #
Green Sheet � 50228
1
2
3
4
5
6
7
8
9
10
11
12
13
14
IS
16
17
18
t9
',0
1
2
3
Presented By�
)���
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
3�
Committee: Date
RESOLVED: That application, ID �34005, for a Gambling Manager's License by Margaret
5t. Sauver DBA East Twins Babe Ruth League, Inc. at Paul's Lounge, 1045
Hudson Road, be and the same is hereby approved.
Requested by Department of:
• - - - - . .
• - .t
By: ��t�w � �
ldoption Certified by Council Secretary
y. `
. t / �
pproved by Mayor: Date #al€�-l� Z-
, � k��= ��
Form Approved by City At�ey
By:
Approved by yor £or Submission to
Council
By:
Adopted by Council: Date Q�,'�_ g\qQ�
�„'_'_�—
FOR
TOTAL # OF SIGNATURE PAGES
N° 5022�
l GREEN SHEE °� � -1a'�8'
INITIAL/OATE INITIALIOATE
DEPARTMENTDIRECTOR �CINCOUNCIL
CI7Y ATTORNEY O GTY CIERK
BUDGET OIRECiOH � PIN- 8 MOT SEflViCES OIR
MAYOR (OR ASSYSTANn �
(CLIP ALL LOCATIONS FOR SIGNATURE}
Margaret St. Sauver DBA East Twins Babe Ruth League, Inc. requests CounciZ
approval of her application for a Gambling Manager`s License, ID �/34005, at Paul's Lounge,
1045 Hudson Road.
NECOMMENDATONS; ApprWB (A) or Rejact (R)
__ FIANNIN6 CqMMISSfON _
__C18CQMM1TfEE _
__ STAFF _
__ DISTRICTCOVRT _ .
SUGPOATS WH�CH CAUNqI O&1ECTIVE?
what,
PERSONAL SERVfGE CONTRACTS MUST ANSWER THE FQItOW�NG QUESTIONS:
t Has Ynis persoMtirm ever worked untler a contract tor this tlepartment�
YES NO
2. Has this person/firm ever been a ciTy emplpyee?
YES NO
3. DoeS this personRirm po5sess a skili not normally passassetl by arry current ciry empioyee�
YES NO
Explaln ali yes anawers on aeparafe aheet antl attach to green sheet
�Y1.
)VANTAGES 1F APPPqVEO
Cit�}u,,�°j� n."`f?�.t'7� is�i§S'+
t� . '.�� N VS ����
�UNTOFTRANSACTION $
COSTIREYENUE BUDGE7E0 (ClRCLE ONE) YES NO
fURCE ACTIVITY NUMBER
�R6aAT10N� (EXPlA1N)
. 9 � � 13��1fr
East STATE OF MINXESOTA . FOR HOARD VSE ONLY
GAMSLZHG CONTROL BOARD AMT. PAID
GAMBLING MANRGEX LICENSE RENEWAL APPLZCATION CHECK #
LC212GMR PRINTED: 07f11f45 DATE
LZCENSE NUMBER: f3-Q1991 001 EFFECTIVE DATE: O1(O1J95 E%PZRATION DATE: 12f31/95
NAHE OF ORGRNZZATZON: Babe Rutb League St Faul East Twius
CiAMBLS126 MNIA6ER INFORMATIOH
Margaret Ana St Sauver
1� , � �7�� 3i'�Y S"
�* � , ` � c �'J'tA-C`Lf J' � 7
7
DAY2IME PHONE NUMBER: 612-7�6-2665
DATE OF BIRTH: 03/07/49
SEXS F
SOCIAL SECURITY NUMBERs 475-58-9?64
MEMSER SINCE: 04/29J86 �}
� J 7 �
LAST DATE YOU ATTENDED A GAMBLING MANAGER5.8EMINAR/CONTINUINQ EDUCATION CLASS: -�6f49�f-94
HOPID INFORMATION
SOND COMFANY NAN,E: Uaited States Fide13 BOND NUMBERs 20003011831926
ACKNOWLED(3MENT
DECLIIRE TftATt
I HAVE R$AD THI�S APPLZCATION AND ALL INFORMATION SUBMITTED TO Tf3E GAMBLING CONTROL BOARD;
ALL INFORMATION IS TRUE, ACCURATE ANR COMPLETE;
ALL OTHBR REqUiRED INFQRMATION HAS�BEEN FULLY DISCLOSED;
Z AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION�
I HAVE 6EEN AN ACTIVE MEMSER OF THE ORGANIZATION FOR AT LEAST TWO YEARS;
L WILL FAMILIARI2E MYSELF WITH THE LAWS OF MINNESOTA GOVERNiNG LAWFUL GAMBLING AND RULES OF
CHE GAMSLING CONTROL BOARA AND AGREE, IF LICENSED, TO AHTDE THOSE LAWS AND RULES,
'.NCLUDING AHEN�MENTS TO THEM�
NY CBANGES ZN APPLICATION IfiFORMATZON 4IILL BE SUSMZTTED 20 THE GAMSLZNG CONTROL BOARD AND
pCAL UNIT OF GOVERNMENT WITHIN 30 DAYS OF THE CHANGE)
V AFFZpAVZT FOR GAM&LING MANAGER HAS HEEN COMPLETED AND RTTACHED� AND
DNDERSTAN4 THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
tFORMATION MAY RESSILT IN THE DEN2AL OR REVOCATION OF THE LZCENSE.
ATURE OF ORMBLIN6 11ANA6ER DATE
REFER TO THE CHECRI.SST FOR REQUIRED ATTAC
MAIL TO: GRMALIN6 CONTROL BOAAD
1711 WEST COUNTY ROAD H, SUITE 3QOS
FOSEVILLE� MINNESOTA 55113
)RM WILL BE MADE AVAILASLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST
� �
LG213
04J18t95
Minnesota Gambling Controi Board
Gambling Manager Affidavit ��7„y�'
Attach to the Gambling Manager Apptication, Form tG2i2 �
�
STATE OF �� pn� 5� ��- 1 ) AFFIDAVIT OF QUALIFICATION
FOR GAMBLING MANAGER LICENSE
� S ' $ ' AND CONSENT S7ATEMENT
GOUNTY OF �, � ) (Pursuant to Minnesota Statutes and Rules)
�,1� I�cn, r_ t" �f ' i � a��� r— , Under oath state that:
( ype/print name)
t. I have never been convicted of a felony or a crime invoiving gambiing.
2. f have not, within five years before the date of the license application, committed a viofation of law or
Board rule that resulied in the revocation of a license issued by ihe 8oarti.
3. i have never been convicted of a criminai violation invo{ving fraud, thefl, tax evasion, misrepresentation,
or gambling.
4. I have neve� been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii)
making terroristic threats.
. �,
5. { am not, nor ever have been connected with or engaged in an illegal business.
6. i do noi owe $500 or more in delinquent taxes as defined in section 27d.72.
7. i have not had a saies and use tax permit revoked by the commissioner of revenue within the past two
year5:
8. I have never, after demand, failed to file tax retums required by the commissioner of revenue.
In addition, I u�derstand, agree and hereby irrevocabiy consent that suits and actions relating to the subject
marier of the attached gambling manager ficense application, or acts or omissions arising from such applica-
tion, may be commenced against my organization and I will accept the service of process for my organiza-
tion in any court of competent }�risdiction in Minnesota by service on the Minnesota Secretary of State af 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 conduct a
criminal background check or review and to share the resuits with the Gambling Controi Board.
=ailure to provide required intormation or providing false or misleading information may resuit in the deniai or
evocaiion of the license.
URTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in
�ppod of the appiication for a gambling manager license from the Gambling Co�trot Board.
NOTARY PUBLfC lNFORMRTION
Seal must be current and correct.
�al may not be altered.
ubscribed and swom to before me this
/.S��fday of `-�e �d fe,Uj j� e 12 19
�
R, SPIELMAh
/ ' // ��C.i.CX Y � � d. �L7�'"'Z�_
� � {signature of applicant)
ORGANIZAT/ON (NFORMAT(ON
of Organization
/�„ <
Council File � 97— �e���
ordinance #
Green Sheet � 50228
1
2
3
4
5
6
7
8
9
10
11
12
13
14
IS
16
17
18
t9
',0
1
2
3
Presented By�
)���
Referred To
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
3�
Committee: Date
RESOLVED: That application, ID �34005, for a Gambling Manager's License by Margaret
5t. Sauver DBA East Twins Babe Ruth League, Inc. at Paul's Lounge, 1045
Hudson Road, be and the same is hereby approved.
Requested by Department of:
• - - - - . .
• - .t
By: ��t�w � �
ldoption Certified by Council Secretary
y. `
. t / �
pproved by Mayor: Date #al€�-l� Z-
, � k��= ��
Form Approved by City At�ey
By:
Approved by yor £or Submission to
Council
By:
Adopted by Council: Date Q�,'�_ g\qQ�
�„'_'_�—
FOR
TOTAL # OF SIGNATURE PAGES
N° 5022�
l GREEN SHEE °� � -1a'�8'
INITIAL/OATE INITIALIOATE
DEPARTMENTDIRECTOR �CINCOUNCIL
CI7Y ATTORNEY O GTY CIERK
BUDGET OIRECiOH � PIN- 8 MOT SEflViCES OIR
MAYOR (OR ASSYSTANn �
(CLIP ALL LOCATIONS FOR SIGNATURE}
Margaret St. Sauver DBA East Twins Babe Ruth League, Inc. requests CounciZ
approval of her application for a Gambling Manager`s License, ID �/34005, at Paul's Lounge,
1045 Hudson Road.
NECOMMENDATONS; ApprWB (A) or Rejact (R)
__ FIANNIN6 CqMMISSfON _
__C18CQMM1TfEE _
__ STAFF _
__ DISTRICTCOVRT _ .
SUGPOATS WH�CH CAUNqI O&1ECTIVE?
what,
PERSONAL SERVfGE CONTRACTS MUST ANSWER THE FQItOW�NG QUESTIONS:
t Has Ynis persoMtirm ever worked untler a contract tor this tlepartment�
YES NO
2. Has this person/firm ever been a ciTy emplpyee?
YES NO
3. DoeS this personRirm po5sess a skili not normally passassetl by arry current ciry empioyee�
YES NO
Explaln ali yes anawers on aeparafe aheet antl attach to green sheet
�Y1.
)VANTAGES 1F APPPqVEO
Cit�}u,,�°j� n."`f?�.t'7� is�i§S'+
t� . '.�� N VS ����
�UNTOFTRANSACTION $
COSTIREYENUE BUDGE7E0 (ClRCLE ONE) YES NO
fURCE ACTIVITY NUMBER
�R6aAT10N� (EXPlA1N)
. 9 � � 13��1fr
East STATE OF MINXESOTA . FOR HOARD VSE ONLY
GAMSLZHG CONTROL BOARD AMT. PAID
GAMBLING MANRGEX LICENSE RENEWAL APPLZCATION CHECK #
LC212GMR PRINTED: 07f11f45 DATE
LZCENSE NUMBER: f3-Q1991 001 EFFECTIVE DATE: O1(O1J95 E%PZRATION DATE: 12f31/95
NAHE OF ORGRNZZATZON: Babe Rutb League St Faul East Twius
CiAMBLS126 MNIA6ER INFORMATIOH
Margaret Ana St Sauver
1� , � �7�� 3i'�Y S"
�* � , ` � c �'J'tA-C`Lf J' � 7
7
DAY2IME PHONE NUMBER: 612-7�6-2665
DATE OF BIRTH: 03/07/49
SEXS F
SOCIAL SECURITY NUMBERs 475-58-9?64
MEMSER SINCE: 04/29J86 �}
� J 7 �
LAST DATE YOU ATTENDED A GAMBLING MANAGER5.8EMINAR/CONTINUINQ EDUCATION CLASS: -�6f49�f-94
HOPID INFORMATION
SOND COMFANY NAN,E: Uaited States Fide13 BOND NUMBERs 20003011831926
ACKNOWLED(3MENT
DECLIIRE TftATt
I HAVE R$AD THI�S APPLZCATION AND ALL INFORMATION SUBMITTED TO Tf3E GAMBLING CONTROL BOARD;
ALL INFORMATION IS TRUE, ACCURATE ANR COMPLETE;
ALL OTHBR REqUiRED INFQRMATION HAS�BEEN FULLY DISCLOSED;
Z AM THE ONLY GAMBLING MANAGER OF THE ORGANIZATION�
I HAVE 6EEN AN ACTIVE MEMSER OF THE ORGANIZATION FOR AT LEAST TWO YEARS;
L WILL FAMILIARI2E MYSELF WITH THE LAWS OF MINNESOTA GOVERNiNG LAWFUL GAMBLING AND RULES OF
CHE GAMSLING CONTROL BOARA AND AGREE, IF LICENSED, TO AHTDE THOSE LAWS AND RULES,
'.NCLUDING AHEN�MENTS TO THEM�
NY CBANGES ZN APPLICATION IfiFORMATZON 4IILL BE SUSMZTTED 20 THE GAMSLZNG CONTROL BOARD AND
pCAL UNIT OF GOVERNMENT WITHIN 30 DAYS OF THE CHANGE)
V AFFZpAVZT FOR GAM&LING MANAGER HAS HEEN COMPLETED AND RTTACHED� AND
DNDERSTAN4 THAT FAILURE TO PROVIDE REQUIRED INFORMATION OR PROVIDING FALSE OR MISLEADING
tFORMATION MAY RESSILT IN THE DEN2AL OR REVOCATION OF THE LZCENSE.
ATURE OF ORMBLIN6 11ANA6ER DATE
REFER TO THE CHECRI.SST FOR REQUIRED ATTAC
MAIL TO: GRMALIN6 CONTROL BOAAD
1711 WEST COUNTY ROAD H, SUITE 3QOS
FOSEVILLE� MINNESOTA 55113
)RM WILL BE MADE AVAILASLE IN ALTERNATIVE FORMAT (I.E. LARGE PRINT, BRAILLE) UPON REQUEST
� �
LG213
04J18t95
Minnesota Gambling Controi Board
Gambling Manager Affidavit ��7„y�'
Attach to the Gambling Manager Apptication, Form tG2i2 �
�
STATE OF �� pn� 5� ��- 1 ) AFFIDAVIT OF QUALIFICATION
FOR GAMBLING MANAGER LICENSE
� S ' $ ' AND CONSENT S7ATEMENT
GOUNTY OF �, � ) (Pursuant to Minnesota Statutes and Rules)
�,1� I�cn, r_ t" �f ' i � a��� r— , Under oath state that:
( ype/print name)
t. I have never been convicted of a felony or a crime invoiving gambiing.
2. f have not, within five years before the date of the license application, committed a viofation of law or
Board rule that resulied in the revocation of a license issued by ihe 8oarti.
3. i have never been convicted of a criminai violation invo{ving fraud, thefl, tax evasion, misrepresentation,
or gambling.
4. I have neve� been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii)
making terroristic threats.
. �,
5. { am not, nor ever have been connected with or engaged in an illegal business.
6. i do noi owe $500 or more in delinquent taxes as defined in section 27d.72.
7. i have not had a saies and use tax permit revoked by the commissioner of revenue within the past two
year5:
8. I have never, after demand, failed to file tax retums required by the commissioner of revenue.
In addition, I u�derstand, agree and hereby irrevocabiy consent that suits and actions relating to the subject
marier of the attached gambling manager ficense application, or acts or omissions arising from such applica-
tion, may be commenced against my organization and I will accept the service of process for my organiza-
tion in any court of competent }�risdiction in Minnesota by service on the Minnesota Secretary of State af 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 conduct a
criminal background check or review and to share the resuits with the Gambling Controi Board.
=ailure to provide required intormation or providing false or misleading information may resuit in the deniai or
evocaiion of the license.
URTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are submitted in
�ppod of the appiication for a gambling manager license from the Gambling Co�trot Board.
NOTARY PUBLfC lNFORMRTION
Seal must be current and correct.
�al may not be altered.
ubscribed and swom to before me this
/.S��fday of `-�e �d fe,Uj j� e 12 19
�
R, SPIELMAh
/ ' // ��C.i.CX Y � � d. �L7�'"'Z�_
� � {signature of applicant)
ORGANIZAT/ON (NFORMAT(ON
of Organization
/�„ <