97-1557Council File#�S�
ordinance #
OR�GINAL
Presented By
Referred To
L, MINNESOTA
� xasoLVan : That appiication (ID #19970000188) for a Gambling Manager License(s)
2 by ERIC A SOLLIEN DBA ALIVENESS PRQJECTlTRIKKX at 49� ROBERT
3 ST N be the same and is hereby approved.
Requested by Department of:
By: ��.� � �
Approved by Mayor: Date ��, 24 �{ },
Office of License, Inspection
Environmental Protection
By: ✓.W� �`�!�
Form Approved by City Attorney
BY� ___�_Z� � �,
Approved by Mayor for Submission
Council
By: �,- v — �G By:
Green Sheet # 50335
Adopted by Council: Date Q�, a� ���
Adoption Certified by Council Secretary
DEPARTMENTiOFFiCE/COUNCIL DATE iNl'nA7E�
LIEP/Licensing GREEN SHEET No. 50335 q� `�SS�
CONTACT PERSON & PHONE
ImfiaWate InitiaVDate
GUNTHER WILLIAM (BfLL)
(612)266-9132 � City Attomey
MUS7 BE ON COUNCIL AGENDA BY (DATE) �SSIGH
� NUMBERFOR , Z '. Council Research
ROUTIHG
6R6ER
T07AL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS POR SIGNATURE)
ACTION REQUESTED
Council approval of the following license application: License #: 19970000188, for: ERIC A
SOLLIEN, Doing Business As: ALIVENESS PROJECTlfRIKKK, at: 490 ROBERT ST N, and type of business(es):
Gambling Manager
RECOMMENDATIONApp�ove(A)RejeCt(R) PERSONALSERVICECONTR4CTSMUSTANSWERTHEFOLLOWINGQUESTIONS:
i Has this person/firtn everworked untler a contract for this department?
PtANNfNG COMMISSfON YES NO
CIB COMMI7TEE 2. Has this person/firtn ever been a ciry employee?
qVIL SVC CINN, vES NO
3. Does this personffrtn possess a skili not normally possessed by any curcent city employee�
YES NO
4. Is this person/firm a targetetl vendo(?
— YES NO
Explain ali yes answers on separate sheet and attach to green sheet
Initiating Problem, Issue, Opportartity (Who, What, When, Where, Why):
Approval of a gambling manager license application.
Advantages If Approved
� �i {,�Ak'6i{�'
DISADVANTAGES IFAPPROVED: DEC O 9 �g�
DISADVANTAGES IF NOT APPROVED
TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE qCTIVITY NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
q�_iss�
Minnesota Lawful Gambling LG2I2
Gambling Manager Application Page , s ofZ
Incomplete, false, or misleading application in�ormation may result in denial of a license.
Organization {nformation
Organization Name A 1 l V P n 2 S S Q r o j e c t
CEONameSCOtt Schlaffman
(Cannof be gambiing manager)
Daytime Phone 6 12 1 8 2 2- 7 9 4 6 Organization Sase License
Board Use On/y:
= Lic :
uence �
n
Gambling Manager Information
First Name E r l C Fuil Middle Name A 1 d rl Last Name S 0 1 1 7� n
Maiden Name Date of Birtfi 3/ 3 J 72 Check one ofthe boxes: X❑ Male � Female
Sociai Security Number 4 6 8-� 9 6 � 4 0 5� DisGasure of
Home StreetAddress � 01 5 W 2 5 t 2 6 t h S t r e° t n 2 0 2 Socia� Security Number
Minneapolis
Daytime Phone Number ( 6 1 � )$ 2 2- 7 9 4
I became an active memberofthis organization on:
1 attended the hvo-day gambling manager seminar on:
You a2 required to provide your soda! secu-
rity numberon this form. Your sociai secu-
rity number will be used to determine your
compliance wdh the tax laws ot Minnesota.
Authorizationfor requitingyoursocialsecu-
rity number is found at 42 U.S.C. 405(c)(i).
Bond Infiormation p• �w 70 , 000 fidelity bond in favor of the organization has been obtained as required
by Minnesota Statutes, section 349.167, subdivision 1.
InsuranceCompanyName: Security Co. BondNumber:68480422
(DO NOT liSE 7HE AGEtVCY NAM�
Gambting Manager Change �en your organization is changing its gambling manager, complete
one of these sections:
EtTtE�g2qcy ChaqgO - Aflow up to five days for OthBC Cha�ge - Al(ow up to ten weeks for processing
processing The new gambiing manage�s license shouid become
The chief executive officer, by signing below, affirms eifeetive (check one):
that the emergency-appiication is due to the following � The day after the curzent gambling manager's license
reason (check one and fifl in date): expires (forexample, ifthe current gambling manager's
❑ Death of gambling manager on / / license expires 7/31/96, the new gambling managers
license becomes effecfive on 8/1/96, provided that all
❑ Bisabifity of gambling manager on / � application information is complete).
� 7e5 i�ati31 � eg ployment of gambling manager on � y�/hen the application has been pracessed by the Gam-
� bling Control Board-the effective date will be the first
NOTE: The new gambling manager may not assume day of the month.
duties until heishe has received fhe gambling manager's NOTE: The new gambling manager may not assume
license from the Gambling Controf Board. duties until he/she has received a gambling manager's
license ftom fhe Gambling Control Board.
Signature of CEO
Su�w w � Sc�.��
Notarized Signature of Chief Executive Officer (CEO)
Date: 'J�'�O � 7
��P� �2 � �
Notary Public Information. Notary Pubiic Seai must
be current and correct; seal may not be altered.
Subscribed and swom to before me this �`�_ day
of . 'Y� c.�v-,_, , 19 � � .
NDiARYPU5LIC—N�rlhc;OTAf�continued on back)
surns�r cour!n i p � 7
Ay Cammr,s'cn Eao'r.0 Jf.N 31. �„(L� { ���p /
Gambling Manager Application (continued)
Affidavit and Consent Statement:
T, (print name) E r i c A 7 a n S o 1 1 i e n
under oath state fhat I have never:
1. been convicted of a felony or a crime involving gam-
bling;
2. committed a violation of law or Board rule thaf resulted
in the revocation of a license issued by fhe Board within
five years before the date ofthe license applicafion;
3, been convicted of a criminal violation invofving fraud,
theft, tax evasion, misrepresentation, or gambiing;
4. been convicted of (i) assault, (ii) a criminal violation
invoiving the use of a firearm, or (iii) making terroristic
threats.
5. been connected wi[h nor engaged in an il(egal busi-
ness;
6, owed $50� or more in delinquent taxes as defined in
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue wifhin the past two years;
8. failedfofile,afterdemand,taxretumsrequiredbythe
commissioner of revanue,
in addition, I understand, agree, and hereby irrevocably
consent that suits and actions relating to fhe subject mat-
ter of the attached gambling manages license application,
' or acts or omissions arising from such application, may be
commenced agains: me or my organization and i wi11
accept the service of process fr, any couR of competent
jurisdiction in Minnesota by service or 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 Departments of Public Safety and Revenue to con-
duct a criminal and tax background check or review and
to share the results with the Gambling Controi Board.
Failure to provide required information or providing faise
or misieading information may result in the denial or
revocation of the license.
FURTHER AFFfANT SAYETH NOT, except that this
A�davit and Consent Statement are submitted in support
of the application for a gambling manager license from
the Gamblinq Control Board.
Signature of Gambling Manager
A c nt
.\
� ., � — -��.__
Notanzed Signature ofApplicant
t�ll�l�-��i��
Date
��- t ss�
LG212
arss
Paqe 2 of 2
This publication wiii be made availabie in alternative
formaf (i.e. �arce print, Braille) upon request If you
use a TTY, you can cail us using the Minnesota Re(ay
Service at 1-800-627-3529 and ask them to place a
call to (612) 639-4000.
The information requested on this form wil( be used
by the Gamblina Control Board (Board) to determine
your compliance with Minnesota s:atutes and rules
goveming lawiul gambling activi6es. All of the infor-
mation that you supply on this form will become
public information when received by the Board.
The information requested on this fortn (including any
attachmentsj will be used by the Board to determine
your qualificaflons to be involved in (awfu! gambfing
activities in Minnesota, and to assist the Board in
conducting a background investigation oi you.
You have the right to refuse to suppiy the information
requested; however, if you refuse to supply this infor-
mation, the Boasd may not be able to determine your
qualifications and, as a consequence, may refuse to
issue you a license. if you suppiy the information
, required, the 8oard will be abie to process your appli-
cation.
Your name and address wiil be pubiic information when
race+ved by the Soard. AIi the other information about
you that you providewiil be private data unfif the Soard ',
issues your {icense. When the Eoard issues your '
4icense, all of the information you have provided to
the Board in the process of appfying for your license
wiil become publicexcepfforyoursociai security num-
ber, which remains private.
If the Board does nof issue you a license, all the infor•
mation you have provided in the process of appiying
for a license remains privaYe, with the exception of
your name and address, which wiii remain public.
Private data about you is availabie only to the follow-
ing: Board members, staff of the Board tivhose work
assignment requires that they have access to the
information; the Minnesota Department of Pubfic
Safety; the Minnesota Attorney General; the Minne-
sota Commissioners of Administraiion, Finance, and
Revenue; the Legisfative Auditor, national and inter-
nafional gambfing regufatory agencies; anyone pur-
suant to courE order; other individuals and agencies
that msy be specificaffy authorized by state or federaf
law ta have access to such information; individuais
and agencies 4or which law or Iegai order aufhorizes a
new use or sharing af the�information after this notice
is given; you; and anyone with your written consent.
Notary Public Information. Notary Public Sea1 must
be current and correct; seal may not be aitered.
Subscribed and swom to before me this �`� �� day
of _ �Y'� ,�-�-r , 19�Z.
i
( �'�`C'�. � �---�
Notary ubiic
� � h-�- r, t;ai c7 iFELlEl�7SCH6fIDT i
��•�_ • ., c' !!',--MINN'e$OTA �
i '�`� � ^.; m�rv 1
Council File#�S�
ordinance #
OR�GINAL
Presented By
Referred To
L, MINNESOTA
� xasoLVan : That appiication (ID #19970000188) for a Gambling Manager License(s)
2 by ERIC A SOLLIEN DBA ALIVENESS PRQJECTlTRIKKX at 49� ROBERT
3 ST N be the same and is hereby approved.
Requested by Department of:
By: ��.� � �
Approved by Mayor: Date ��, 24 �{ },
Office of License, Inspection
Environmental Protection
By: ✓.W� �`�!�
Form Approved by City Attorney
BY� ___�_Z� � �,
Approved by Mayor for Submission
Council
By: �,- v — �G By:
Green Sheet # 50335
Adopted by Council: Date Q�, a� ���
Adoption Certified by Council Secretary
DEPARTMENTiOFFiCE/COUNCIL DATE iNl'nA7E�
LIEP/Licensing GREEN SHEET No. 50335 q� `�SS�
CONTACT PERSON & PHONE
ImfiaWate InitiaVDate
GUNTHER WILLIAM (BfLL)
(612)266-9132 � City Attomey
MUS7 BE ON COUNCIL AGENDA BY (DATE) �SSIGH
� NUMBERFOR , Z '. Council Research
ROUTIHG
6R6ER
T07AL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS POR SIGNATURE)
ACTION REQUESTED
Council approval of the following license application: License #: 19970000188, for: ERIC A
SOLLIEN, Doing Business As: ALIVENESS PROJECTlfRIKKK, at: 490 ROBERT ST N, and type of business(es):
Gambling Manager
RECOMMENDATIONApp�ove(A)RejeCt(R) PERSONALSERVICECONTR4CTSMUSTANSWERTHEFOLLOWINGQUESTIONS:
i Has this person/firtn everworked untler a contract for this department?
PtANNfNG COMMISSfON YES NO
CIB COMMI7TEE 2. Has this person/firtn ever been a ciry employee?
qVIL SVC CINN, vES NO
3. Does this personffrtn possess a skili not normally possessed by any curcent city employee�
YES NO
4. Is this person/firm a targetetl vendo(?
— YES NO
Explain ali yes answers on separate sheet and attach to green sheet
Initiating Problem, Issue, Opportartity (Who, What, When, Where, Why):
Approval of a gambling manager license application.
Advantages If Approved
� �i {,�Ak'6i{�'
DISADVANTAGES IFAPPROVED: DEC O 9 �g�
DISADVANTAGES IF NOT APPROVED
TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE qCTIVITY NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
q�_iss�
Minnesota Lawful Gambling LG2I2
Gambling Manager Application Page , s ofZ
Incomplete, false, or misleading application in�ormation may result in denial of a license.
Organization {nformation
Organization Name A 1 l V P n 2 S S Q r o j e c t
CEONameSCOtt Schlaffman
(Cannof be gambiing manager)
Daytime Phone 6 12 1 8 2 2- 7 9 4 6 Organization Sase License
Board Use On/y:
= Lic :
uence �
n
Gambling Manager Information
First Name E r l C Fuil Middle Name A 1 d rl Last Name S 0 1 1 7� n
Maiden Name Date of Birtfi 3/ 3 J 72 Check one ofthe boxes: X❑ Male � Female
Sociai Security Number 4 6 8-� 9 6 � 4 0 5� DisGasure of
Home StreetAddress � 01 5 W 2 5 t 2 6 t h S t r e° t n 2 0 2 Socia� Security Number
Minneapolis
Daytime Phone Number ( 6 1 � )$ 2 2- 7 9 4
I became an active memberofthis organization on:
1 attended the hvo-day gambling manager seminar on:
You a2 required to provide your soda! secu-
rity numberon this form. Your sociai secu-
rity number will be used to determine your
compliance wdh the tax laws ot Minnesota.
Authorizationfor requitingyoursocialsecu-
rity number is found at 42 U.S.C. 405(c)(i).
Bond Infiormation p• �w 70 , 000 fidelity bond in favor of the organization has been obtained as required
by Minnesota Statutes, section 349.167, subdivision 1.
InsuranceCompanyName: Security Co. BondNumber:68480422
(DO NOT liSE 7HE AGEtVCY NAM�
Gambting Manager Change �en your organization is changing its gambling manager, complete
one of these sections:
EtTtE�g2qcy ChaqgO - Aflow up to five days for OthBC Cha�ge - Al(ow up to ten weeks for processing
processing The new gambiing manage�s license shouid become
The chief executive officer, by signing below, affirms eifeetive (check one):
that the emergency-appiication is due to the following � The day after the curzent gambling manager's license
reason (check one and fifl in date): expires (forexample, ifthe current gambling manager's
❑ Death of gambling manager on / / license expires 7/31/96, the new gambling managers
license becomes effecfive on 8/1/96, provided that all
❑ Bisabifity of gambling manager on / � application information is complete).
� 7e5 i�ati31 � eg ployment of gambling manager on � y�/hen the application has been pracessed by the Gam-
� bling Control Board-the effective date will be the first
NOTE: The new gambling manager may not assume day of the month.
duties until heishe has received fhe gambling manager's NOTE: The new gambling manager may not assume
license from the Gambling Controf Board. duties until he/she has received a gambling manager's
license ftom fhe Gambling Control Board.
Signature of CEO
Su�w w � Sc�.��
Notarized Signature of Chief Executive Officer (CEO)
Date: 'J�'�O � 7
��P� �2 � �
Notary Public Information. Notary Pubiic Seai must
be current and correct; seal may not be altered.
Subscribed and swom to before me this �`�_ day
of . 'Y� c.�v-,_, , 19 � � .
NDiARYPU5LIC—N�rlhc;OTAf�continued on back)
surns�r cour!n i p � 7
Ay Cammr,s'cn Eao'r.0 Jf.N 31. �„(L� { ���p /
Gambling Manager Application (continued)
Affidavit and Consent Statement:
T, (print name) E r i c A 7 a n S o 1 1 i e n
under oath state fhat I have never:
1. been convicted of a felony or a crime involving gam-
bling;
2. committed a violation of law or Board rule thaf resulted
in the revocation of a license issued by fhe Board within
five years before the date ofthe license applicafion;
3, been convicted of a criminal violation invofving fraud,
theft, tax evasion, misrepresentation, or gambiing;
4. been convicted of (i) assault, (ii) a criminal violation
invoiving the use of a firearm, or (iii) making terroristic
threats.
5. been connected wi[h nor engaged in an il(egal busi-
ness;
6, owed $50� or more in delinquent taxes as defined in
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue wifhin the past two years;
8. failedfofile,afterdemand,taxretumsrequiredbythe
commissioner of revanue,
in addition, I understand, agree, and hereby irrevocably
consent that suits and actions relating to fhe subject mat-
ter of the attached gambling manages license application,
' or acts or omissions arising from such application, may be
commenced agains: me or my organization and i wi11
accept the service of process fr, any couR of competent
jurisdiction in Minnesota by service or 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 Departments of Public Safety and Revenue to con-
duct a criminal and tax background check or review and
to share the results with the Gambling Controi Board.
Failure to provide required information or providing faise
or misieading information may result in the denial or
revocation of the license.
FURTHER AFFfANT SAYETH NOT, except that this
A�davit and Consent Statement are submitted in support
of the application for a gambling manager license from
the Gamblinq Control Board.
Signature of Gambling Manager
A c nt
.\
� ., � — -��.__
Notanzed Signature ofApplicant
t�ll�l�-��i��
Date
��- t ss�
LG212
arss
Paqe 2 of 2
This publication wiii be made availabie in alternative
formaf (i.e. �arce print, Braille) upon request If you
use a TTY, you can cail us using the Minnesota Re(ay
Service at 1-800-627-3529 and ask them to place a
call to (612) 639-4000.
The information requested on this form wil( be used
by the Gamblina Control Board (Board) to determine
your compliance with Minnesota s:atutes and rules
goveming lawiul gambling activi6es. All of the infor-
mation that you supply on this form will become
public information when received by the Board.
The information requested on this fortn (including any
attachmentsj will be used by the Board to determine
your qualificaflons to be involved in (awfu! gambfing
activities in Minnesota, and to assist the Board in
conducting a background investigation oi you.
You have the right to refuse to suppiy the information
requested; however, if you refuse to supply this infor-
mation, the Boasd may not be able to determine your
qualifications and, as a consequence, may refuse to
issue you a license. if you suppiy the information
, required, the 8oard will be abie to process your appli-
cation.
Your name and address wiil be pubiic information when
race+ved by the Soard. AIi the other information about
you that you providewiil be private data unfif the Soard ',
issues your {icense. When the Eoard issues your '
4icense, all of the information you have provided to
the Board in the process of appfying for your license
wiil become publicexcepfforyoursociai security num-
ber, which remains private.
If the Board does nof issue you a license, all the infor•
mation you have provided in the process of appiying
for a license remains privaYe, with the exception of
your name and address, which wiii remain public.
Private data about you is availabie only to the follow-
ing: Board members, staff of the Board tivhose work
assignment requires that they have access to the
information; the Minnesota Department of Pubfic
Safety; the Minnesota Attorney General; the Minne-
sota Commissioners of Administraiion, Finance, and
Revenue; the Legisfative Auditor, national and inter-
nafional gambfing regufatory agencies; anyone pur-
suant to courE order; other individuals and agencies
that msy be specificaffy authorized by state or federaf
law ta have access to such information; individuais
and agencies 4or which law or Iegai order aufhorizes a
new use or sharing af the�information after this notice
is given; you; and anyone with your written consent.
Notary Public Information. Notary Public Sea1 must
be current and correct; seal may not be aitered.
Subscribed and swom to before me this �`� �� day
of _ �Y'� ,�-�-r , 19�Z.
i
( �'�`C'�. � �---�
Notary ubiic
� � h-�- r, t;ai c7 iFELlEl�7SCH6fIDT i
��•�_ • ., c' !!',--MINN'e$OTA �
i '�`� � ^.; m�rv 1
Council File#�S�
ordinance #
OR�GINAL
Presented By
Referred To
L, MINNESOTA
� xasoLVan : That appiication (ID #19970000188) for a Gambling Manager License(s)
2 by ERIC A SOLLIEN DBA ALIVENESS PRQJECTlTRIKKX at 49� ROBERT
3 ST N be the same and is hereby approved.
Requested by Department of:
By: ��.� � �
Approved by Mayor: Date ��, 24 �{ },
Office of License, Inspection
Environmental Protection
By: ✓.W� �`�!�
Form Approved by City Attorney
BY� ___�_Z� � �,
Approved by Mayor for Submission
Council
By: �,- v — �G By:
Green Sheet # 50335
Adopted by Council: Date Q�, a� ���
Adoption Certified by Council Secretary
DEPARTMENTiOFFiCE/COUNCIL DATE iNl'nA7E�
LIEP/Licensing GREEN SHEET No. 50335 q� `�SS�
CONTACT PERSON & PHONE
ImfiaWate InitiaVDate
GUNTHER WILLIAM (BfLL)
(612)266-9132 � City Attomey
MUS7 BE ON COUNCIL AGENDA BY (DATE) �SSIGH
� NUMBERFOR , Z '. Council Research
ROUTIHG
6R6ER
T07AL # OF SIGNATURE PAGES (CLIP ALL LOCATIONS POR SIGNATURE)
ACTION REQUESTED
Council approval of the following license application: License #: 19970000188, for: ERIC A
SOLLIEN, Doing Business As: ALIVENESS PROJECTlfRIKKK, at: 490 ROBERT ST N, and type of business(es):
Gambling Manager
RECOMMENDATIONApp�ove(A)RejeCt(R) PERSONALSERVICECONTR4CTSMUSTANSWERTHEFOLLOWINGQUESTIONS:
i Has this person/firtn everworked untler a contract for this department?
PtANNfNG COMMISSfON YES NO
CIB COMMI7TEE 2. Has this person/firtn ever been a ciry employee?
qVIL SVC CINN, vES NO
3. Does this personffrtn possess a skili not normally possessed by any curcent city employee�
YES NO
4. Is this person/firm a targetetl vendo(?
— YES NO
Explain ali yes answers on separate sheet and attach to green sheet
Initiating Problem, Issue, Opportartity (Who, What, When, Where, Why):
Approval of a gambling manager license application.
Advantages If Approved
� �i {,�Ak'6i{�'
DISADVANTAGES IFAPPROVED: DEC O 9 �g�
DISADVANTAGES IF NOT APPROVED
TOTAL AMOUNT OF TRANSACTION $ COST/REVENUE BUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE qCTIVITY NUMBER
FINANCIAL INFORMATION: (EXPLAIN)
q�_iss�
Minnesota Lawful Gambling LG2I2
Gambling Manager Application Page , s ofZ
Incomplete, false, or misleading application in�ormation may result in denial of a license.
Organization {nformation
Organization Name A 1 l V P n 2 S S Q r o j e c t
CEONameSCOtt Schlaffman
(Cannof be gambiing manager)
Daytime Phone 6 12 1 8 2 2- 7 9 4 6 Organization Sase License
Board Use On/y:
= Lic :
uence �
n
Gambling Manager Information
First Name E r l C Fuil Middle Name A 1 d rl Last Name S 0 1 1 7� n
Maiden Name Date of Birtfi 3/ 3 J 72 Check one ofthe boxes: X❑ Male � Female
Sociai Security Number 4 6 8-� 9 6 � 4 0 5� DisGasure of
Home StreetAddress � 01 5 W 2 5 t 2 6 t h S t r e° t n 2 0 2 Socia� Security Number
Minneapolis
Daytime Phone Number ( 6 1 � )$ 2 2- 7 9 4
I became an active memberofthis organization on:
1 attended the hvo-day gambling manager seminar on:
You a2 required to provide your soda! secu-
rity numberon this form. Your sociai secu-
rity number will be used to determine your
compliance wdh the tax laws ot Minnesota.
Authorizationfor requitingyoursocialsecu-
rity number is found at 42 U.S.C. 405(c)(i).
Bond Infiormation p• �w 70 , 000 fidelity bond in favor of the organization has been obtained as required
by Minnesota Statutes, section 349.167, subdivision 1.
InsuranceCompanyName: Security Co. BondNumber:68480422
(DO NOT liSE 7HE AGEtVCY NAM�
Gambting Manager Change �en your organization is changing its gambling manager, complete
one of these sections:
EtTtE�g2qcy ChaqgO - Aflow up to five days for OthBC Cha�ge - Al(ow up to ten weeks for processing
processing The new gambiing manage�s license shouid become
The chief executive officer, by signing below, affirms eifeetive (check one):
that the emergency-appiication is due to the following � The day after the curzent gambling manager's license
reason (check one and fifl in date): expires (forexample, ifthe current gambling manager's
❑ Death of gambling manager on / / license expires 7/31/96, the new gambling managers
license becomes effecfive on 8/1/96, provided that all
❑ Bisabifity of gambling manager on / � application information is complete).
� 7e5 i�ati31 � eg ployment of gambling manager on � y�/hen the application has been pracessed by the Gam-
� bling Control Board-the effective date will be the first
NOTE: The new gambling manager may not assume day of the month.
duties until heishe has received fhe gambling manager's NOTE: The new gambling manager may not assume
license from the Gambling Controf Board. duties until he/she has received a gambling manager's
license ftom fhe Gambling Control Board.
Signature of CEO
Su�w w � Sc�.��
Notarized Signature of Chief Executive Officer (CEO)
Date: 'J�'�O � 7
��P� �2 � �
Notary Public Information. Notary Pubiic Seai must
be current and correct; seal may not be altered.
Subscribed and swom to before me this �`�_ day
of . 'Y� c.�v-,_, , 19 � � .
NDiARYPU5LIC—N�rlhc;OTAf�continued on back)
surns�r cour!n i p � 7
Ay Cammr,s'cn Eao'r.0 Jf.N 31. �„(L� { ���p /
Gambling Manager Application (continued)
Affidavit and Consent Statement:
T, (print name) E r i c A 7 a n S o 1 1 i e n
under oath state fhat I have never:
1. been convicted of a felony or a crime involving gam-
bling;
2. committed a violation of law or Board rule thaf resulted
in the revocation of a license issued by fhe Board within
five years before the date ofthe license applicafion;
3, been convicted of a criminal violation invofving fraud,
theft, tax evasion, misrepresentation, or gambiing;
4. been convicted of (i) assault, (ii) a criminal violation
invoiving the use of a firearm, or (iii) making terroristic
threats.
5. been connected wi[h nor engaged in an il(egal busi-
ness;
6, owed $50� or more in delinquent taxes as defined in
section 270.72;
7. had a sales and use tax permit revoked by the com-
missioner of revenue wifhin the past two years;
8. failedfofile,afterdemand,taxretumsrequiredbythe
commissioner of revanue,
in addition, I understand, agree, and hereby irrevocably
consent that suits and actions relating to fhe subject mat-
ter of the attached gambling manages license application,
' or acts or omissions arising from such application, may be
commenced agains: me or my organization and i wi11
accept the service of process fr, any couR of competent
jurisdiction in Minnesota by service or 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 Departments of Public Safety and Revenue to con-
duct a criminal and tax background check or review and
to share the results with the Gambling Controi Board.
Failure to provide required information or providing faise
or misieading information may result in the denial or
revocation of the license.
FURTHER AFFfANT SAYETH NOT, except that this
A�davit and Consent Statement are submitted in support
of the application for a gambling manager license from
the Gamblinq Control Board.
Signature of Gambling Manager
A c nt
.\
� ., � — -��.__
Notanzed Signature ofApplicant
t�ll�l�-��i��
Date
��- t ss�
LG212
arss
Paqe 2 of 2
This publication wiii be made availabie in alternative
formaf (i.e. �arce print, Braille) upon request If you
use a TTY, you can cail us using the Minnesota Re(ay
Service at 1-800-627-3529 and ask them to place a
call to (612) 639-4000.
The information requested on this form wil( be used
by the Gamblina Control Board (Board) to determine
your compliance with Minnesota s:atutes and rules
goveming lawiul gambling activi6es. All of the infor-
mation that you supply on this form will become
public information when received by the Board.
The information requested on this fortn (including any
attachmentsj will be used by the Board to determine
your qualificaflons to be involved in (awfu! gambfing
activities in Minnesota, and to assist the Board in
conducting a background investigation oi you.
You have the right to refuse to suppiy the information
requested; however, if you refuse to supply this infor-
mation, the Boasd may not be able to determine your
qualifications and, as a consequence, may refuse to
issue you a license. if you suppiy the information
, required, the 8oard will be abie to process your appli-
cation.
Your name and address wiil be pubiic information when
race+ved by the Soard. AIi the other information about
you that you providewiil be private data unfif the Soard ',
issues your {icense. When the Eoard issues your '
4icense, all of the information you have provided to
the Board in the process of appfying for your license
wiil become publicexcepfforyoursociai security num-
ber, which remains private.
If the Board does nof issue you a license, all the infor•
mation you have provided in the process of appiying
for a license remains privaYe, with the exception of
your name and address, which wiii remain public.
Private data about you is availabie only to the follow-
ing: Board members, staff of the Board tivhose work
assignment requires that they have access to the
information; the Minnesota Department of Pubfic
Safety; the Minnesota Attorney General; the Minne-
sota Commissioners of Administraiion, Finance, and
Revenue; the Legisfative Auditor, national and inter-
nafional gambfing regufatory agencies; anyone pur-
suant to courE order; other individuals and agencies
that msy be specificaffy authorized by state or federaf
law ta have access to such information; individuais
and agencies 4or which law or Iegai order aufhorizes a
new use or sharing af the�information after this notice
is given; you; and anyone with your written consent.
Notary Public Information. Notary Public Sea1 must
be current and correct; seal may not be aitered.
Subscribed and swom to before me this �`� �� day
of _ �Y'� ,�-�-r , 19�Z.
i
( �'�`C'�. � �---�
Notary ubiic
� � h-�- r, t;ai c7 iFELlEl�7SCH6fIDT i
��•�_ • ., c' !!',--MINN'e$OTA �
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