97-3821
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
�-,, T-. ��
;�, % n��'° ;� �.'�:-._�
Presented
Referred To
Committee: Date
RESOLVED: That application, ID 11632, for a new Gambling Manager•s License by Raren
L. Wirkus DBA CLIMB at Kick-Off, 1347 Burns Avenue, be and the same is
hereby approved.
Requested by Department of:
• - -:-- :-•- •:- ,:.
R •�fl'I - •f
By: �/.c�ce�.H �' 4�Ira�
Adoption Certified by Council Secretary
By: � � a� (�,a-,�,.,�_
Approved by Mayor: Date G( t7�
By: ' � ✓ �
Council File # � _ 3 g �
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Ordinance #
Green Sheet # 35450
TT ,
Form Approved by City Attorney
By:
Approoed by Mayor for Submission to
Council
By:
Adopted by Council: Date ry�� ��q�
GREEN SHEET
TOTAL # OF SI(
4?- 3�'�+
N_ 35450
INIT7AVDATE —�
u DEPAHrMENT DIRECTOR u GITY COUNCIL
� O CITY ATfORNEY � C�N CLERK
� BUDGET DIRECTOfl � FlN. & MGT. SE
■ O MAVOR (OR ASSISTANn ❑
(CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Karen L. Wirkus DBA CLIMB requests Council approval of her application €or a
new Gambling Manager's License at Kick-Off, 1347"Burns Avenue (ID 4I11632):
m
_ PIANNING COMMISSION _ CIVIlSEflVICE COMM1$SION
_ CIB COMMI7TEE _
_ STAFP _
� DISTRICTCAURT `
SUPPORTS WNICH COUNCiI OBJECT4YE?
PEflSONAL SERVICE CONTNACTS MUST ANSWER TNE FOLLOWING �UESTIONS:
1. Has U�is persoNiirtn ever worked under a coMracl frn tFns tleparimeM? -
YES NO
2. Has Nis person/firm ever bean a city employee?
YES NO
3. Does this personttirm possess a skill not normally possassetl by any curcent city employee?
YES NO
Explain all yes answers on separate sheet antl atteeh to green sheet
(NTO. Wl�et, When, Where, Why):
MAR 18 1987
�° ���a� �� EY
� . ��� �����
��4R 2 4 19��
TOTAL AMOUNT OF TRANSACTION
COST/REVENUE BUDGETED (CIRCLE ONE)
YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
FINANCIAI INFOFiMATION: (�XPLAIN) '
Greensheet# 35450 L.I.E.P. REVIEW CHECKLIST Date: / 9� •3$''�'
In Tracker? 3�/�4��t7 npp�n aeceived / App'n Processed
License ID # 11632 Ucense Type: cambi �ng ManagPr
Company Name: Karen �. Wirkus _ D6A: 1•fMB
8usinessAddresss:_�'��� Rnrna pve_ (K;ck—offl _ BusinessPfione: 27-9660
Cornact NamejAddress: 500 Y3o. Robert St. 55101 Home Phone: 227-466�
Date to Council Researcfi: ������q�
Pubtic Hearing Date: �� 4 !�'f� Labels Ordered:
Notice Sent to Applicant:� ��P'7 District Council #_ 04
Notice Sent to Public: /� Ward #: 07
DepartmeM/ Date fnspections Comments
City Attorney / f
3/°�/�
/ Q !
Environmental
Health
���
�
Fire
/V / /7
1
License siee aian Received:_
lxasa Re�ived:
�� �
i
Police ���l �e-�T„/ �e� ���[�
` 7 (b t/r�
��
Zoning
N�!/
•East �, STATE OF MINNESOTA "LOR BO RD US3 ��
GAMBLING CONTROL BOARD AMT. PAZD
GAM6LZNG MANAGER LICENSE RENEWAL APPLSCATION CHECK #`
LG212GMR PRINTED: 09/OS/95 DATE
LICENSE NUMBERs 6-02002 002 EFFECTIVE DATE: Q3/O1/96 EXPIRATION DATEt �2/29/96
NAME OF ORGANIZATIONt Climb St Paul
a
GAASBLSNC3 MANAGER SNFORMATIOLi
Raren Lea Wirkus
55"<: Crosby Ave E
Iaver Grove Heights MN 55076
c�AYTIME pKONE NUMBERs�612-227-9660
DATE OF BIRTH: 10/24/63
SEX: F
SOCIAL SECURITY NUMBER: 471-46-7872
P.�iEMBER,SINCE: 11/07/89
1!/ l P/95
Y.7iST DATE YOU ATTENDED A CAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLRSS: 11.�12-/-93
BOND INFORM}1TION
�OND COMPANY NAME: Horth River Ins Co BOND NUMBER: 426011202
ACKNOWLEDGMENT
� S DECLI�RE THAT: . � . •
-� Z HAVE READ THIS APPL'aCATZON AND ALL INFORMATION SUBMITTED TO THE GAMBLSNG CONTROL SOARD)�
° ALL INFORMATION YS TRU£� ACCURATE AND COMPLETE; .
�• AL;, OTHER REQUIREA INFORMATION HAS BEEN FULLY DISCLOSED7
° Z AM THE ONLY GAMBLSNG MANAGER OF THE ORGANIZATIONJ
° I HAVE BE&N AN ACTIVE MEMBER OF THE ORGAN:ZATION FOR AT LEAST TWO YEARS�
• I WILL PAMILTAFiI2E MYSBLF WITH THE LAWS OF MINNESOTA GOVSRNING LAWFUL GAMBLING AND RULES OF
THE GAMSLING CONTROL BOARD AND AGREE� IF LZCENSED� TO AHIDE Tt20SE LAWS AND RULES�
INCLUDING AMENDMENTS TQ THEMj � �
° ANY�CHANGES ,IN APPLICATSON �INFORMATION WSLL 6E SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHSN 10 DAYS OF THE CHANGEj
^ AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHEDj AND
• I t7NDER5TANA THRT FAILURE TO PROVIDE REQUSRED 2NFORMATION OR PROVZDSNG FALSE OR MISLEADTNG
INFORMATZON MAY RESULT IN THE DENIAL 4R REVOCATION OF THE LICENSE.
SIGNATURE OF�GAMBLINt3 NANAGER
REFEA TO THE CHECKLIST FOR REQUZRED ATTACHMEKTS
- MAIL TOt GAMBLIN6 CONTROL BOARD
_ ' 1711 WEST COUNTY ROAD 8� SUITE 30p3
ROSEVSLLE� MINNESOTA 55113
DATE
�
TNSS FORM WILL 8E MADE AVAILABLE ZN ALTERNATIVE FORh4AT (I.E. LARCE PRINT, BRAILLEj UPON REQUEST.
L7�
//,6�3oC..
Y9/l/!l1GJVLP ..�q,,,w,,,, .,.,,,�,.,, ,.�..W�.,
oaneiss Gambling Manager Atfidavit
Attach to the Gambling Manager Appl�cation, Form LG212 0`� ����
STATE OF �� )
AFFIDAVlT OF QUAL4F4CATION
) s.s. FOR GAMBLlNG MANAGER IICEMSE
COl1NTY O � AND CONSENT STATEMENT
(Pursuant to Minnesota Statutes and Rules)
�. `f'IA/YA� �• wltih�uS , Undef oath state that;
(type/print name)
1. I have never been convicied of a felony or a crime Invofving gambling.
2. i have not, within five years before ihe date of the license application, committed a violation of law or
Board rvle tha! resulted in the revocation of a Ilcense issued by the Board.
3. I have never been convicted o( a criminal violation invoiving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. ! have never bean convicted of (i) assault, (ii) a criminal violation involvi�g the use of a firearm, or (iii}
making terroristic threats.
5, i am not, nor ever have been connecied wiih or engaged in an iliegal business.
6. I do not owe 5500 or more in delinquent taxes as defined in section 270.72.
7. E have not had a sa{es and use tax permit revoked by the commissioner of revenue within the past two
years.
8. i have never, after demand, failed to file tax retums required by the commissioner of revenue,
!n addifion, 1 understand, agree and heraby irrevocably consent that suits and actions relafing Co ihe subJec4
matter oi the attached gambling manager licensa 8pplication, or acts or omissions arising from such app!ica-
iion, may be commenced against my organization and i wiii accept the service o( process 1or my organiza-
tlo� in any cQUri of competent }urisd'+ction in Minnesota by service on the Minnasota Seaetary of 6t2te of any
summons, process or pteading auiho�zed by the laws of Minnesota.
By signature o( 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 Control Board.
Faiiure to provide required informatior, or providing-talse or misieading information may result In the denial or
revocation of ihe license.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are su6mitted ln
support of the app(icalion for a gambiing manager license from ihe Gambiing Conlroi Board.
NOTARY PUBl.IC /NFORMAT/ON ��.; � ^ -_ 1 / • /__ �
in���� iS. �/��
Notary Pub{ic Seal must be current and coRect, (sig�ature o( applicant)
Seal may not be aliered.
Subscribed and swom to befor me t
��'F� day ot ��'��'%�C.f/ 19?
L-;1.1Jr,�.�,�1 �/t-t1.�
_ ; ;;f YJf'tiXJM?,�`�10N EXPIRES
�/ JANUAB'f 31, Y000
.. ___,.,,�..,
ORGAN/ZAT/ON /NFORMATION
me ol Organization
C.�h��3 ��1eqlre s tJC.,
e Ucense Number
O�OC =-.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
�-,, T-. ��
;�, % n��'° ;� �.'�:-._�
Presented
Referred To
Committee: Date
RESOLVED: That application, ID 11632, for a new Gambling Manager•s License by Raren
L. Wirkus DBA CLIMB at Kick-Off, 1347 Burns Avenue, be and the same is
hereby approved.
Requested by Department of:
• - -:-- :-•- •:- ,:.
R •�fl'I - •f
By: �/.c�ce�.H �' 4�Ira�
Adoption Certified by Council Secretary
By: � � a� (�,a-,�,.,�_
Approved by Mayor: Date G( t7�
By: ' � ✓ �
Council File # � _ 3 g �
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Ordinance #
Green Sheet # 35450
TT ,
Form Approved by City Attorney
By:
Approoed by Mayor for Submission to
Council
By:
Adopted by Council: Date ry�� ��q�
GREEN SHEET
TOTAL # OF SI(
4?- 3�'�+
N_ 35450
INIT7AVDATE —�
u DEPAHrMENT DIRECTOR u GITY COUNCIL
� O CITY ATfORNEY � C�N CLERK
� BUDGET DIRECTOfl � FlN. & MGT. SE
■ O MAVOR (OR ASSISTANn ❑
(CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Karen L. Wirkus DBA CLIMB requests Council approval of her application €or a
new Gambling Manager's License at Kick-Off, 1347"Burns Avenue (ID 4I11632):
m
_ PIANNING COMMISSION _ CIVIlSEflVICE COMM1$SION
_ CIB COMMI7TEE _
_ STAFP _
� DISTRICTCAURT `
SUPPORTS WNICH COUNCiI OBJECT4YE?
PEflSONAL SERVICE CONTNACTS MUST ANSWER TNE FOLLOWING �UESTIONS:
1. Has U�is persoNiirtn ever worked under a coMracl frn tFns tleparimeM? -
YES NO
2. Has Nis person/firm ever bean a city employee?
YES NO
3. Does this personttirm possess a skill not normally possassetl by any curcent city employee?
YES NO
Explain all yes answers on separate sheet antl atteeh to green sheet
(NTO. Wl�et, When, Where, Why):
MAR 18 1987
�° ���a� �� EY
� . ��� �����
��4R 2 4 19��
TOTAL AMOUNT OF TRANSACTION
COST/REVENUE BUDGETED (CIRCLE ONE)
YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
FINANCIAI INFOFiMATION: (�XPLAIN) '
Greensheet# 35450 L.I.E.P. REVIEW CHECKLIST Date: / 9� •3$''�'
In Tracker? 3�/�4��t7 npp�n aeceived / App'n Processed
License ID # 11632 Ucense Type: cambi �ng ManagPr
Company Name: Karen �. Wirkus _ D6A: 1•fMB
8usinessAddresss:_�'��� Rnrna pve_ (K;ck—offl _ BusinessPfione: 27-9660
Cornact NamejAddress: 500 Y3o. Robert St. 55101 Home Phone: 227-466�
Date to Council Researcfi: ������q�
Pubtic Hearing Date: �� 4 !�'f� Labels Ordered:
Notice Sent to Applicant:� ��P'7 District Council #_ 04
Notice Sent to Public: /� Ward #: 07
DepartmeM/ Date fnspections Comments
City Attorney / f
3/°�/�
/ Q !
Environmental
Health
���
�
Fire
/V / /7
1
License siee aian Received:_
lxasa Re�ived:
�� �
i
Police ���l �e-�T„/ �e� ���[�
` 7 (b t/r�
��
Zoning
N�!/
•East �, STATE OF MINNESOTA "LOR BO RD US3 ��
GAMBLING CONTROL BOARD AMT. PAZD
GAM6LZNG MANAGER LICENSE RENEWAL APPLSCATION CHECK #`
LG212GMR PRINTED: 09/OS/95 DATE
LICENSE NUMBERs 6-02002 002 EFFECTIVE DATE: Q3/O1/96 EXPIRATION DATEt �2/29/96
NAME OF ORGANIZATIONt Climb St Paul
a
GAASBLSNC3 MANAGER SNFORMATIOLi
Raren Lea Wirkus
55"<: Crosby Ave E
Iaver Grove Heights MN 55076
c�AYTIME pKONE NUMBERs�612-227-9660
DATE OF BIRTH: 10/24/63
SEX: F
SOCIAL SECURITY NUMBER: 471-46-7872
P.�iEMBER,SINCE: 11/07/89
1!/ l P/95
Y.7iST DATE YOU ATTENDED A CAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLRSS: 11.�12-/-93
BOND INFORM}1TION
�OND COMPANY NAME: Horth River Ins Co BOND NUMBER: 426011202
ACKNOWLEDGMENT
� S DECLI�RE THAT: . � . •
-� Z HAVE READ THIS APPL'aCATZON AND ALL INFORMATION SUBMITTED TO THE GAMBLSNG CONTROL SOARD)�
° ALL INFORMATION YS TRU£� ACCURATE AND COMPLETE; .
�• AL;, OTHER REQUIREA INFORMATION HAS BEEN FULLY DISCLOSED7
° Z AM THE ONLY GAMBLSNG MANAGER OF THE ORGANIZATIONJ
° I HAVE BE&N AN ACTIVE MEMBER OF THE ORGAN:ZATION FOR AT LEAST TWO YEARS�
• I WILL PAMILTAFiI2E MYSBLF WITH THE LAWS OF MINNESOTA GOVSRNING LAWFUL GAMBLING AND RULES OF
THE GAMSLING CONTROL BOARD AND AGREE� IF LZCENSED� TO AHIDE Tt20SE LAWS AND RULES�
INCLUDING AMENDMENTS TQ THEMj � �
° ANY�CHANGES ,IN APPLICATSON �INFORMATION WSLL 6E SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHSN 10 DAYS OF THE CHANGEj
^ AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHEDj AND
• I t7NDER5TANA THRT FAILURE TO PROVIDE REQUSRED 2NFORMATION OR PROVZDSNG FALSE OR MISLEADTNG
INFORMATZON MAY RESULT IN THE DENIAL 4R REVOCATION OF THE LICENSE.
SIGNATURE OF�GAMBLINt3 NANAGER
REFEA TO THE CHECKLIST FOR REQUZRED ATTACHMEKTS
- MAIL TOt GAMBLIN6 CONTROL BOARD
_ ' 1711 WEST COUNTY ROAD 8� SUITE 30p3
ROSEVSLLE� MINNESOTA 55113
DATE
�
TNSS FORM WILL 8E MADE AVAILABLE ZN ALTERNATIVE FORh4AT (I.E. LARCE PRINT, BRAILLEj UPON REQUEST.
L7�
//,6�3oC..
Y9/l/!l1GJVLP ..�q,,,w,,,, .,.,,,�,.,, ,.�..W�.,
oaneiss Gambling Manager Atfidavit
Attach to the Gambling Manager Appl�cation, Form LG212 0`� ����
STATE OF �� )
AFFIDAVlT OF QUAL4F4CATION
) s.s. FOR GAMBLlNG MANAGER IICEMSE
COl1NTY O � AND CONSENT STATEMENT
(Pursuant to Minnesota Statutes and Rules)
�. `f'IA/YA� �• wltih�uS , Undef oath state that;
(type/print name)
1. I have never been convicied of a felony or a crime Invofving gambling.
2. i have not, within five years before ihe date of the license application, committed a violation of law or
Board rvle tha! resulted in the revocation of a Ilcense issued by the Board.
3. I have never been convicted o( a criminal violation invoiving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. ! have never bean convicted of (i) assault, (ii) a criminal violation involvi�g the use of a firearm, or (iii}
making terroristic threats.
5, i am not, nor ever have been connecied wiih or engaged in an iliegal business.
6. I do not owe 5500 or more in delinquent taxes as defined in section 270.72.
7. E have not had a sa{es and use tax permit revoked by the commissioner of revenue within the past two
years.
8. i have never, after demand, failed to file tax retums required by the commissioner of revenue,
!n addifion, 1 understand, agree and heraby irrevocably consent that suits and actions relafing Co ihe subJec4
matter oi the attached gambling manager licensa 8pplication, or acts or omissions arising from such app!ica-
iion, may be commenced against my organization and i wiii accept the service o( process 1or my organiza-
tlo� in any cQUri of competent }urisd'+ction in Minnesota by service on the Minnasota Seaetary of 6t2te of any
summons, process or pteading auiho�zed by the laws of Minnesota.
By signature o( 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 Control Board.
Faiiure to provide required informatior, or providing-talse or misieading information may result In the denial or
revocation of ihe license.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are su6mitted ln
support of the app(icalion for a gambiing manager license from ihe Gambiing Conlroi Board.
NOTARY PUBl.IC /NFORMAT/ON ��.; � ^ -_ 1 / • /__ �
in���� iS. �/��
Notary Pub{ic Seal must be current and coRect, (sig�ature o( applicant)
Seal may not be aliered.
Subscribed and swom to befor me t
��'F� day ot ��'��'%�C.f/ 19?
L-;1.1Jr,�.�,�1 �/t-t1.�
_ ; ;;f YJf'tiXJM?,�`�10N EXPIRES
�/ JANUAB'f 31, Y000
.. ___,.,,�..,
ORGAN/ZAT/ON /NFORMATION
me ol Organization
C.�h��3 ��1eqlre s tJC.,
e Ucense Number
O�OC =-.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
�-,, T-. ��
;�, % n��'° ;� �.'�:-._�
Presented
Referred To
Committee: Date
RESOLVED: That application, ID 11632, for a new Gambling Manager•s License by Raren
L. Wirkus DBA CLIMB at Kick-Off, 1347 Burns Avenue, be and the same is
hereby approved.
Requested by Department of:
• - -:-- :-•- •:- ,:.
R •�fl'I - •f
By: �/.c�ce�.H �' 4�Ira�
Adoption Certified by Council Secretary
By: � � a� (�,a-,�,.,�_
Approved by Mayor: Date G( t7�
By: ' � ✓ �
Council File # � _ 3 g �
RESOLUTION
CITY OF SAINT PAUL, MINNESOTA
Ordinance #
Green Sheet # 35450
TT ,
Form Approved by City Attorney
By:
Approoed by Mayor for Submission to
Council
By:
Adopted by Council: Date ry�� ��q�
GREEN SHEET
TOTAL # OF SI(
4?- 3�'�+
N_ 35450
INIT7AVDATE —�
u DEPAHrMENT DIRECTOR u GITY COUNCIL
� O CITY ATfORNEY � C�N CLERK
� BUDGET DIRECTOfl � FlN. & MGT. SE
■ O MAVOR (OR ASSISTANn ❑
(CLIP ALL LOCATIONS FOR SIGNATURE)
ACTION REQUESTED:
Karen L. Wirkus DBA CLIMB requests Council approval of her application €or a
new Gambling Manager's License at Kick-Off, 1347"Burns Avenue (ID 4I11632):
m
_ PIANNING COMMISSION _ CIVIlSEflVICE COMM1$SION
_ CIB COMMI7TEE _
_ STAFP _
� DISTRICTCAURT `
SUPPORTS WNICH COUNCiI OBJECT4YE?
PEflSONAL SERVICE CONTNACTS MUST ANSWER TNE FOLLOWING �UESTIONS:
1. Has U�is persoNiirtn ever worked under a coMracl frn tFns tleparimeM? -
YES NO
2. Has Nis person/firm ever bean a city employee?
YES NO
3. Does this personttirm possess a skill not normally possassetl by any curcent city employee?
YES NO
Explain all yes answers on separate sheet antl atteeh to green sheet
(NTO. Wl�et, When, Where, Why):
MAR 18 1987
�° ���a� �� EY
� . ��� �����
��4R 2 4 19��
TOTAL AMOUNT OF TRANSACTION
COST/REVENUE BUDGETED (CIRCLE ONE)
YES NO
FUNDIHG SOURCE ACTIVITY NUMBER
FINANCIAI INFOFiMATION: (�XPLAIN) '
Greensheet# 35450 L.I.E.P. REVIEW CHECKLIST Date: / 9� •3$''�'
In Tracker? 3�/�4��t7 npp�n aeceived / App'n Processed
License ID # 11632 Ucense Type: cambi �ng ManagPr
Company Name: Karen �. Wirkus _ D6A: 1•fMB
8usinessAddresss:_�'��� Rnrna pve_ (K;ck—offl _ BusinessPfione: 27-9660
Cornact NamejAddress: 500 Y3o. Robert St. 55101 Home Phone: 227-466�
Date to Council Researcfi: ������q�
Pubtic Hearing Date: �� 4 !�'f� Labels Ordered:
Notice Sent to Applicant:� ��P'7 District Council #_ 04
Notice Sent to Public: /� Ward #: 07
DepartmeM/ Date fnspections Comments
City Attorney / f
3/°�/�
/ Q !
Environmental
Health
���
�
Fire
/V / /7
1
License siee aian Received:_
lxasa Re�ived:
�� �
i
Police ���l �e-�T„/ �e� ���[�
` 7 (b t/r�
��
Zoning
N�!/
•East �, STATE OF MINNESOTA "LOR BO RD US3 ��
GAMBLING CONTROL BOARD AMT. PAZD
GAM6LZNG MANAGER LICENSE RENEWAL APPLSCATION CHECK #`
LG212GMR PRINTED: 09/OS/95 DATE
LICENSE NUMBERs 6-02002 002 EFFECTIVE DATE: Q3/O1/96 EXPIRATION DATEt �2/29/96
NAME OF ORGANIZATIONt Climb St Paul
a
GAASBLSNC3 MANAGER SNFORMATIOLi
Raren Lea Wirkus
55"<: Crosby Ave E
Iaver Grove Heights MN 55076
c�AYTIME pKONE NUMBERs�612-227-9660
DATE OF BIRTH: 10/24/63
SEX: F
SOCIAL SECURITY NUMBER: 471-46-7872
P.�iEMBER,SINCE: 11/07/89
1!/ l P/95
Y.7iST DATE YOU ATTENDED A CAMBLING MANAGERS SEMINAR/CONTINUING EDUCATION CLRSS: 11.�12-/-93
BOND INFORM}1TION
�OND COMPANY NAME: Horth River Ins Co BOND NUMBER: 426011202
ACKNOWLEDGMENT
� S DECLI�RE THAT: . � . •
-� Z HAVE READ THIS APPL'aCATZON AND ALL INFORMATION SUBMITTED TO THE GAMBLSNG CONTROL SOARD)�
° ALL INFORMATION YS TRU£� ACCURATE AND COMPLETE; .
�• AL;, OTHER REQUIREA INFORMATION HAS BEEN FULLY DISCLOSED7
° Z AM THE ONLY GAMBLSNG MANAGER OF THE ORGANIZATIONJ
° I HAVE BE&N AN ACTIVE MEMBER OF THE ORGAN:ZATION FOR AT LEAST TWO YEARS�
• I WILL PAMILTAFiI2E MYSBLF WITH THE LAWS OF MINNESOTA GOVSRNING LAWFUL GAMBLING AND RULES OF
THE GAMSLING CONTROL BOARD AND AGREE� IF LZCENSED� TO AHIDE Tt20SE LAWS AND RULES�
INCLUDING AMENDMENTS TQ THEMj � �
° ANY�CHANGES ,IN APPLICATSON �INFORMATION WSLL 6E SUBMITTED TO THE GAMBLING CONTROL BOARD AND
LOCAL UNIT OF GOVERNMENT WITHSN 10 DAYS OF THE CHANGEj
^ AN AFFIDAVIT FOR GAMBLING MANAGER HAS BEEN COMPLETED AND ATTACHEDj AND
• I t7NDER5TANA THRT FAILURE TO PROVIDE REQUSRED 2NFORMATION OR PROVZDSNG FALSE OR MISLEADTNG
INFORMATZON MAY RESULT IN THE DENIAL 4R REVOCATION OF THE LICENSE.
SIGNATURE OF�GAMBLINt3 NANAGER
REFEA TO THE CHECKLIST FOR REQUZRED ATTACHMEKTS
- MAIL TOt GAMBLIN6 CONTROL BOARD
_ ' 1711 WEST COUNTY ROAD 8� SUITE 30p3
ROSEVSLLE� MINNESOTA 55113
DATE
�
TNSS FORM WILL 8E MADE AVAILABLE ZN ALTERNATIVE FORh4AT (I.E. LARCE PRINT, BRAILLEj UPON REQUEST.
L7�
//,6�3oC..
Y9/l/!l1GJVLP ..�q,,,w,,,, .,.,,,�,.,, ,.�..W�.,
oaneiss Gambling Manager Atfidavit
Attach to the Gambling Manager Appl�cation, Form LG212 0`� ����
STATE OF �� )
AFFIDAVlT OF QUAL4F4CATION
) s.s. FOR GAMBLlNG MANAGER IICEMSE
COl1NTY O � AND CONSENT STATEMENT
(Pursuant to Minnesota Statutes and Rules)
�. `f'IA/YA� �• wltih�uS , Undef oath state that;
(type/print name)
1. I have never been convicied of a felony or a crime Invofving gambling.
2. i have not, within five years before ihe date of the license application, committed a violation of law or
Board rvle tha! resulted in the revocation of a Ilcense issued by the Board.
3. I have never been convicted o( a criminal violation invoiving fraud, theft, tax evasion, misrepresentation,
or gambling.
4. ! have never bean convicted of (i) assault, (ii) a criminal violation involvi�g the use of a firearm, or (iii}
making terroristic threats.
5, i am not, nor ever have been connecied wiih or engaged in an iliegal business.
6. I do not owe 5500 or more in delinquent taxes as defined in section 270.72.
7. E have not had a sa{es and use tax permit revoked by the commissioner of revenue within the past two
years.
8. i have never, after demand, failed to file tax retums required by the commissioner of revenue,
!n addifion, 1 understand, agree and heraby irrevocably consent that suits and actions relafing Co ihe subJec4
matter oi the attached gambling manager licensa 8pplication, or acts or omissions arising from such app!ica-
iion, may be commenced against my organization and i wiii accept the service o( process 1or my organiza-
tlo� in any cQUri of competent }urisd'+ction in Minnesota by service on the Minnasota Seaetary of 6t2te of any
summons, process or pteading auiho�zed by the laws of Minnesota.
By signature o( 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 Control Board.
Faiiure to provide required informatior, or providing-talse or misieading information may result In the denial or
revocation of ihe license.
FURTHER AFFIANT SAYETH NOT, except that this Affidavit and Consent Statement are su6mitted ln
support of the app(icalion for a gambiing manager license from ihe Gambiing Conlroi Board.
NOTARY PUBl.IC /NFORMAT/ON ��.; � ^ -_ 1 / • /__ �
in���� iS. �/��
Notary Pub{ic Seal must be current and coRect, (sig�ature o( applicant)
Seal may not be aliered.
Subscribed and swom to befor me t
��'F� day ot ��'��'%�C.f/ 19?
L-;1.1Jr,�.�,�1 �/t-t1.�
_ ; ;;f YJf'tiXJM?,�`�10N EXPIRES
�/ JANUAB'f 31, Y000
.. ___,.,,�..,
ORGAN/ZAT/ON /NFORMATION
me ol Organization
C.�h��3 ��1eqlre s tJC.,
e Ucense Number
O�OC =-.