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98-143flRIG1NAL RESOLUTION Presented By Referred To C1TY OF SAINT PAUL, MINNESOTA Council File# 9� -!y3 ordinance $ Green Sheet # LP60019 3 `� Committee: Date RESOL{7ED: 1 That application (ID #19980000002) tor a Gambling Manager License(s) 2 by BARBARA DOTTY-THOMAS DBA SEXUAL VIOLENCE CENTER/CLVB METRO 3 at 733 PIERCE BUTLER ROUTE be and the same is hereby approved. Requested by Department of: Adoption Certi£ied by Council secretary By: _T \ � �_ Approved by Mayor: ] By: Office of License, Inspections and Environmental Protection ! �1 Form by City Attorney ��12� Z -� -9� Approved by Mayor for Submission to Council By: Adopted by Council: Date '� �o` 3.S ��` i GREEN SHEET WILLIAM (Bill) ON COUNCIL AGENDA BY (DATE) 1❑ City AttomeY 2� Counc�l Research No,LP60019 �" �� TOTAt #t OF SiGNATtiRE PAGES tCIJP ALL LOCASIONS FOR SIGNATUR� ACTION REQUESTED: Counal appraral oithe tdfaving Gcense applkation: License # 199800000U2, for BARBARA DOTTY-THOMAS, Doing Business As SEXllAL VIOLENCE CENTER/CLUB METRO, at 733 PIERCE BUTLER ROUTE, inGUdi�g the fdbwirg business type(s): Gamtrling Manager. RECOMMENDATIONS: Approve(A) Reject(R) , PLANNMG COMMiSSION , CIB COMMITTEE CIVIL SVC CINN, 2SONAL SERVICE CONTRAf:TS MUST ANSWER THE POLL0IMNG QUES710N5: Has this perbo�rtn aver worketl under e conhaIX fw this departmenl? YES NO Has this pe�rm ever been a cdy empbyee4 �s rio Daes this pe�rm Dossess a skill not rrocmalN P� bY �Y curreM eity empiqeea YES NO Is ihis personlfmm a Urgated vendoR YES NO 4 Expwin an yes answers on separate sheet and aaach m green sheet �� PROBIEM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why): Council approrai fa Barbara Doty-Thomas fw a Gambiing Managefs License at 733 Pierce Butler Rou[e. �+,, �� ; �" �'?v ess�'��`' � e.�. _ . . �� IF IF NOT APPROVED: �OTAL AMOUN7 OF TRANSACTION $ 'UNDING SOURCE 'tNANCIAL INPORMA710N: :XPIAlN) COSTIREVENUE BUDGETED (CIRCLE ONEj YfS NO AC7IVITY NUM6ER 1 Minnesota Law,fui C�aumbling Gambling Manager .} U° �� 'a'1 (�9�'�.. _ _ � Incompiete, false, or misleading application information may resuit in denial of a license. Organization Infarmation Organization CEOName ` r ` (Cannothegamblingmaqager) .. DaytimePhone � !.�� 'a �a�'�L OrganizationBaseLicense Gambling Manager Information Frst Name � l�2t� f'-� �la Full Middle Name Maiden Name � 6 � Date of Birth�_( x in /�2_ Sociai SecuriTy iVumber tl �1 ° �o t? ' �l �b � HomeStreetAddress �1 �.a Y' +��b�1�� r�r., S�' , t� r� 1a.L. __ State rn� ZiP� Daytime Phone Number ( �.0 �� ) a c�% �- I became an active member of this organization on: l attended the two-day gambting manager seminar on: Discfosure of Social Sscurity Numher You are required to provide your social sew- rityaumheronthisform.Your socialsecu- rity numberwiil be used to detertnine your compliance wRh the tax �aws of Minnesota. Authorization for requiring your sociai secu- � rity number is found at 42 U.S.C. 405(c)(i). ��. �_ r: Bond Information A$10,000 fidelity bond in favor of the organization has 6een obtained as required by Minnesota Statutes, section 349.167, subdivision 1. insurance Company Name: 'S ��,��'� �h� m0.2iNfBOnd Number. � K f) {� f �() .� �! g� (DO N07 USE THE AGENCY NAME) _ � When your organization is changing Rs gambling manager, com Gambling Manager Change one of these sections: °' � t t p4 �Fnr nrk&�s. Emergency Cfiange - a��ow up to flve days tor processing The chief executive officer, by signing below, a�rms that the emergency appiication is due to the fo4lowing reason (check one and fil! in date): Death of gambiing manager on _ Disability of gambfing manager on Other Change - Aliow up o en we The new gambling manager's license effective (check one): � TY�e day after the current gambling man - e�. �� expires (for example, if the current gambling IScense exoires 7l31/96, the new gambiing manager's license 6ecomes effective on 8/1/96, provided that alf appiication infortnation is complete). � When the appiication has been processed by the Gam- 6ling Control Board—the effective date wiil be the first day of the month. h10TE: The new gambling manager may not assume duties until heJshe has received a gambling manager's license From the Gambling Controt Board. � Termination of empioyment of gambling manager on �_�.��.�'� . NOTE: The new gambling manager may not assume duties until helshe has received the gambling managers Iicense from the Gambling Conttol Board. Signature of CE� � ti� NotarizedSignature fGhiefExecu6v fficer(CEO) Date: ! � � � � / Notary Public Information. Notary Pubiic Seai must be current and correct; seal may not be altere,�. Subscrib and swom to before me this �I day of ^^ .�n^^—^^PA' ?q^n"h - //, .� �`..'� DELIA M. K � q�-14' �� l ,�p ° � ' � � J Boan �1 e Lic # �'� uence # wt Paid� � ck # 1 `f' ` �IS �P ¢'� � ��. \ \ \ �. , ,.� r Z..r,w,n r i Checkoneoftheboxes: � Male � Femaie l� � �^ iq ,��?� ��a 3 �� _� ��, � 1.V_IS'�/ �' �--�. "1- � �7l<✓� -�^1�_`'�(Q . W C (tL�(A- �' �-b'el� �w'/�M,�'\f.O[1a��4l� ��.� �(SG�I�.'T l�f.R+�. iv Q.r.yL�„g� /�v.^/\�. O-4A.m-A-^ C� /3.J-e. �ri2L"Y� �- K-c _�/� /� G � ��' OJ:I Wd-�J Gambling Manager Aj��lication (continue Affidavit and Consent � I, (print name) 3 C�Y h GY A. 1� under oath state that 1 have never: �. been convicted oY a felony or a cnme involving gam- bling; 2. committed a violation of faw or Board rule that resulted in the revocation of a license issued by the Board within five years before the date of the ficense application; 3. been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation, or gambling; 4. been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii) making tenoristic threats. 5. been connected with nor engaged in an iilegai busi- ness; 6. owed $500 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 within the past two years; 8. faited to fife, after demand, tax retums required by the commissioner of revenue. in addition, l understand, agree, and hereby irrevocabiy consent that suits and actions relafing to the subject mat- terof the attached gambling manager4icense application, or acts or omissions arising from such applica6on, may 6e commenced against me or my organization and ! wili accept the service of process in any court of competent jurisdiction in Minnesota by service on the Minnesota Secreiary of State of any summons, process, or pieading 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 criminai and tax background check or review and to share the results with the Gambling Contro! Board. Fai)ure to provide required information or providing faise or misleading !.^.PC�f.^i3 may , in [he deniai or revocation of the license. FURTNER AFf1ANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the application for a gambfing manager license from the Gamblinq Controi Board. Signature of Gambting Manager Appiicant � G:�1 � ma� Notarized Signature otAppliwnt �o �� - �77 �i�-l4 � LCf2A�2 �'g � .siss' Page 2 of 2 . -� •�` 7his publication will be made available in alternative format (i.e. farge print, Braiile) upon request. If you use a TTY, you can call us using the Minnesota Refay Service at 1-800-627-3529 and ask them to piaCe a caii to (6i2) 639-4000. The i�formation requested on this form will be used by the Gambiing Controi Board (Board) to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. All of the infor- mation that you supply on this form wili become public information when received by the Board. The information requested on this form (including any � attachments) wifl be used by the Board to determine your qualifications to be invotved in lawfui gambling aCtivities in Minnesota, and to assist the Board in 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- S;loiiGi�� :ilc ° uGaiu iu'ay ��vi uc 84iE iu G6ic�iuill6 y/OUf qualifications and, as a consequence, may refuse to issue you a license. if you supply the information required, the Board wili be able to process your appli- cation. Your name and address wiii be public information when received by the Board. Aif the other information about you that you provide will be private data until the Board issues your license. When the Board issues your--'� license, afl of the information you have provided to the Board in the process of applying for your ficense will become puh(ic excepf for your social secu rity 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 applying for a license remains private, with the exception of yaur name and address, which wiil remain pubiic. Private data about you is avaifabie onfy to the foliow- ing: Board members, staff of the Soard whose work assignment requires that they have access to the information; the Minnesota Department of Pubiic Safety; the Minnesota Atforney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the �egisiative Auditor; nationai and inter- n=t;�na� ga�� liny �eyu{aiory agencies; anyone pur- suant to couR order; other individuals and agencies that may be specifically authorized by state or federal law to have access to such information; individuais 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 Pubiic information. Notary Pub�ic Seai must be curtent and corcect; seal may not be altered. Subs i nd sworn to 6efore me this �� day o �._. _. „-,� , 1 9 � -� _. --�- flRIG1NAL RESOLUTION Presented By Referred To C1TY OF SAINT PAUL, MINNESOTA Council File# 9� -!y3 ordinance $ Green Sheet # LP60019 3 `� Committee: Date RESOL{7ED: 1 That application (ID #19980000002) tor a Gambling Manager License(s) 2 by BARBARA DOTTY-THOMAS DBA SEXUAL VIOLENCE CENTER/CLVB METRO 3 at 733 PIERCE BUTLER ROUTE be and the same is hereby approved. Requested by Department of: Adoption Certi£ied by Council secretary By: _T \ � �_ Approved by Mayor: ] By: Office of License, Inspections and Environmental Protection ! �1 Form by City Attorney ��12� Z -� -9� Approved by Mayor for Submission to Council By: Adopted by Council: Date '� �o` 3.S ��` i GREEN SHEET WILLIAM (Bill) ON COUNCIL AGENDA BY (DATE) 1❑ City AttomeY 2� Counc�l Research No,LP60019 �" �� TOTAt #t OF SiGNATtiRE PAGES tCIJP ALL LOCASIONS FOR SIGNATUR� ACTION REQUESTED: Counal appraral oithe tdfaving Gcense applkation: License # 199800000U2, for BARBARA DOTTY-THOMAS, Doing Business As SEXllAL VIOLENCE CENTER/CLUB METRO, at 733 PIERCE BUTLER ROUTE, inGUdi�g the fdbwirg business type(s): Gamtrling Manager. RECOMMENDATIONS: Approve(A) Reject(R) , PLANNMG COMMiSSION , CIB COMMITTEE CIVIL SVC CINN, 2SONAL SERVICE CONTRAf:TS MUST ANSWER THE POLL0IMNG QUES710N5: Has this perbo�rtn aver worketl under e conhaIX fw this departmenl? YES NO Has this pe�rm ever been a cdy empbyee4 �s rio Daes this pe�rm Dossess a skill not rrocmalN P� bY �Y curreM eity empiqeea YES NO Is ihis personlfmm a Urgated vendoR YES NO 4 Expwin an yes answers on separate sheet and aaach m green sheet �� PROBIEM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why): Council approrai fa Barbara Doty-Thomas fw a Gambiing Managefs License at 733 Pierce Butler Rou[e. �+,, �� ; �" �'?v ess�'��`' � e.�. _ . . �� IF IF NOT APPROVED: �OTAL AMOUN7 OF TRANSACTION $ 'UNDING SOURCE 'tNANCIAL INPORMA710N: :XPIAlN) COSTIREVENUE BUDGETED (CIRCLE ONEj YfS NO AC7IVITY NUM6ER 1 Minnesota Law,fui C�aumbling Gambling Manager .} U° �� 'a'1 (�9�'�.. _ _ � Incompiete, false, or misleading application information may resuit in denial of a license. Organization Infarmation Organization CEOName ` r ` (Cannothegamblingmaqager) .. DaytimePhone � !.�� 'a �a�'�L OrganizationBaseLicense Gambling Manager Information Frst Name � l�2t� f'-� �la Full Middle Name Maiden Name � 6 � Date of Birth�_( x in /�2_ Sociai SecuriTy iVumber tl �1 ° �o t? ' �l �b � HomeStreetAddress �1 �.a Y' +��b�1�� r�r., S�' , t� r� 1a.L. __ State rn� ZiP� Daytime Phone Number ( �.0 �� ) a c�% �- I became an active member of this organization on: l attended the two-day gambting manager seminar on: Discfosure of Social Sscurity Numher You are required to provide your social sew- rityaumheronthisform.Your socialsecu- rity numberwiil be used to detertnine your compliance wRh the tax �aws of Minnesota. Authorization for requiring your sociai secu- � rity number is found at 42 U.S.C. 405(c)(i). ��. �_ r: Bond Information A$10,000 fidelity bond in favor of the organization has 6een obtained as required by Minnesota Statutes, section 349.167, subdivision 1. insurance Company Name: 'S ��,��'� �h� m0.2iNfBOnd Number. � K f) {� f �() .� �! g� (DO N07 USE THE AGENCY NAME) _ � When your organization is changing Rs gambling manager, com Gambling Manager Change one of these sections: °' � t t p4 �Fnr nrk&�s. Emergency Cfiange - a��ow up to flve days tor processing The chief executive officer, by signing below, a�rms that the emergency appiication is due to the fo4lowing reason (check one and fil! in date): Death of gambiing manager on _ Disability of gambfing manager on Other Change - Aliow up o en we The new gambling manager's license effective (check one): � TY�e day after the current gambling man - e�. �� expires (for example, if the current gambling IScense exoires 7l31/96, the new gambiing manager's license 6ecomes effective on 8/1/96, provided that alf appiication infortnation is complete). � When the appiication has been processed by the Gam- 6ling Control Board—the effective date wiil be the first day of the month. h10TE: The new gambling manager may not assume duties until heJshe has received a gambling manager's license From the Gambling Controt Board. � Termination of empioyment of gambling manager on �_�.��.�'� . NOTE: The new gambling manager may not assume duties until helshe has received the gambling managers Iicense from the Gambling Conttol Board. Signature of CE� � ti� NotarizedSignature fGhiefExecu6v fficer(CEO) Date: ! � � � � / Notary Public Information. Notary Pubiic Seai must be current and correct; seal may not be altere,�. Subscrib and swom to before me this �I day of ^^ .�n^^—^^PA' ?q^n"h - //, .� �`..'� DELIA M. K � q�-14' �� l ,�p ° � ' � � J Boan �1 e Lic # �'� uence # wt Paid� � ck # 1 `f' ` �IS �P ¢'� � ��. \ \ \ �. , ,.� r Z..r,w,n r i Checkoneoftheboxes: � Male � Femaie l� � �^ iq ,��?� ��a 3 �� _� ��, � 1.V_IS'�/ �' �--�. "1- � �7l<✓� -�^1�_`'�(Q . W C (tL�(A- �' �-b'el� �w'/�M,�'\f.O[1a��4l� ��.� �(SG�I�.'T l�f.R+�. iv Q.r.yL�„g� /�v.^/\�. O-4A.m-A-^ C� /3.J-e. �ri2L"Y� �- K-c _�/� /� G � ��' OJ:I Wd-�J Gambling Manager Aj��lication (continue Affidavit and Consent � I, (print name) 3 C�Y h GY A. 1� under oath state that 1 have never: �. been convicted oY a felony or a cnme involving gam- bling; 2. committed a violation of faw or Board rule that resulted in the revocation of a license issued by the Board within five years before the date of the ficense application; 3. been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation, or gambling; 4. been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii) making tenoristic threats. 5. been connected with nor engaged in an iilegai busi- ness; 6. owed $500 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 within the past two years; 8. faited to fife, after demand, tax retums required by the commissioner of revenue. in addition, l understand, agree, and hereby irrevocabiy consent that suits and actions relafing to the subject mat- terof the attached gambling manager4icense application, or acts or omissions arising from such applica6on, may 6e commenced against me or my organization and ! wili accept the service of process in any court of competent jurisdiction in Minnesota by service on the Minnesota Secreiary of State of any summons, process, or pieading 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 criminai and tax background check or review and to share the results with the Gambling Contro! Board. Fai)ure to provide required information or providing faise or misleading !.^.PC�f.^i3 may , in [he deniai or revocation of the license. FURTNER AFf1ANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the application for a gambfing manager license from the Gamblinq Controi Board. Signature of Gambting Manager Appiicant � G:�1 � ma� Notarized Signature otAppliwnt �o �� - �77 �i�-l4 � LCf2A�2 �'g � .siss' Page 2 of 2 . -� •�` 7his publication will be made available in alternative format (i.e. farge print, Braiile) upon request. If you use a TTY, you can call us using the Minnesota Refay Service at 1-800-627-3529 and ask them to piaCe a caii to (6i2) 639-4000. The i�formation requested on this form will be used by the Gambiing Controi Board (Board) to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. All of the infor- mation that you supply on this form wili become public information when received by the Board. The information requested on this form (including any � attachments) wifl be used by the Board to determine your qualifications to be invotved in lawfui gambling aCtivities in Minnesota, and to assist the Board in 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- S;loiiGi�� :ilc ° uGaiu iu'ay ��vi uc 84iE iu G6ic�iuill6 y/OUf qualifications and, as a consequence, may refuse to issue you a license. if you supply the information required, the Board wili be able to process your appli- cation. Your name and address wiii be public information when received by the Board. Aif the other information about you that you provide will be private data until the Board issues your license. When the Board issues your--'� license, afl of the information you have provided to the Board in the process of applying for your ficense will become puh(ic excepf for your social secu rity 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 applying for a license remains private, with the exception of yaur name and address, which wiil remain pubiic. Private data about you is avaifabie onfy to the foliow- ing: Board members, staff of the Soard whose work assignment requires that they have access to the information; the Minnesota Department of Pubiic Safety; the Minnesota Atforney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the �egisiative Auditor; nationai and inter- n=t;�na� ga�� liny �eyu{aiory agencies; anyone pur- suant to couR order; other individuals and agencies that may be specifically authorized by state or federal law to have access to such information; individuais 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 Pubiic information. Notary Pub�ic Seai must be curtent and corcect; seal may not be altered. Subs i nd sworn to 6efore me this �� day o �._. _. „-,� , 1 9 � -� _. --�- flRIG1NAL RESOLUTION Presented By Referred To C1TY OF SAINT PAUL, MINNESOTA Council File# 9� -!y3 ordinance $ Green Sheet # LP60019 3 `� Committee: Date RESOL{7ED: 1 That application (ID #19980000002) tor a Gambling Manager License(s) 2 by BARBARA DOTTY-THOMAS DBA SEXUAL VIOLENCE CENTER/CLVB METRO 3 at 733 PIERCE BUTLER ROUTE be and the same is hereby approved. Requested by Department of: Adoption Certi£ied by Council secretary By: _T \ � �_ Approved by Mayor: ] By: Office of License, Inspections and Environmental Protection ! �1 Form by City Attorney ��12� Z -� -9� Approved by Mayor for Submission to Council By: Adopted by Council: Date '� �o` 3.S ��` i GREEN SHEET WILLIAM (Bill) ON COUNCIL AGENDA BY (DATE) 1❑ City AttomeY 2� Counc�l Research No,LP60019 �" �� TOTAt #t OF SiGNATtiRE PAGES tCIJP ALL LOCASIONS FOR SIGNATUR� ACTION REQUESTED: Counal appraral oithe tdfaving Gcense applkation: License # 199800000U2, for BARBARA DOTTY-THOMAS, Doing Business As SEXllAL VIOLENCE CENTER/CLUB METRO, at 733 PIERCE BUTLER ROUTE, inGUdi�g the fdbwirg business type(s): Gamtrling Manager. RECOMMENDATIONS: Approve(A) Reject(R) , PLANNMG COMMiSSION , CIB COMMITTEE CIVIL SVC CINN, 2SONAL SERVICE CONTRAf:TS MUST ANSWER THE POLL0IMNG QUES710N5: Has this perbo�rtn aver worketl under e conhaIX fw this departmenl? YES NO Has this pe�rm ever been a cdy empbyee4 �s rio Daes this pe�rm Dossess a skill not rrocmalN P� bY �Y curreM eity empiqeea YES NO Is ihis personlfmm a Urgated vendoR YES NO 4 Expwin an yes answers on separate sheet and aaach m green sheet �� PROBIEM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why): Council approrai fa Barbara Doty-Thomas fw a Gambiing Managefs License at 733 Pierce Butler Rou[e. �+,, �� ; �" �'?v ess�'��`' � e.�. _ . . �� IF IF NOT APPROVED: �OTAL AMOUN7 OF TRANSACTION $ 'UNDING SOURCE 'tNANCIAL INPORMA710N: :XPIAlN) COSTIREVENUE BUDGETED (CIRCLE ONEj YfS NO AC7IVITY NUM6ER 1 Minnesota Law,fui C�aumbling Gambling Manager .} U° �� 'a'1 (�9�'�.. _ _ � Incompiete, false, or misleading application information may resuit in denial of a license. Organization Infarmation Organization CEOName ` r ` (Cannothegamblingmaqager) .. DaytimePhone � !.�� 'a �a�'�L OrganizationBaseLicense Gambling Manager Information Frst Name � l�2t� f'-� �la Full Middle Name Maiden Name � 6 � Date of Birth�_( x in /�2_ Sociai SecuriTy iVumber tl �1 ° �o t? ' �l �b � HomeStreetAddress �1 �.a Y' +��b�1�� r�r., S�' , t� r� 1a.L. __ State rn� ZiP� Daytime Phone Number ( �.0 �� ) a c�% �- I became an active member of this organization on: l attended the two-day gambting manager seminar on: Discfosure of Social Sscurity Numher You are required to provide your social sew- rityaumheronthisform.Your socialsecu- rity numberwiil be used to detertnine your compliance wRh the tax �aws of Minnesota. Authorization for requiring your sociai secu- � rity number is found at 42 U.S.C. 405(c)(i). ��. �_ r: Bond Information A$10,000 fidelity bond in favor of the organization has 6een obtained as required by Minnesota Statutes, section 349.167, subdivision 1. insurance Company Name: 'S ��,��'� �h� m0.2iNfBOnd Number. � K f) {� f �() .� �! g� (DO N07 USE THE AGENCY NAME) _ � When your organization is changing Rs gambling manager, com Gambling Manager Change one of these sections: °' � t t p4 �Fnr nrk&�s. Emergency Cfiange - a��ow up to flve days tor processing The chief executive officer, by signing below, a�rms that the emergency appiication is due to the fo4lowing reason (check one and fil! in date): Death of gambiing manager on _ Disability of gambfing manager on Other Change - Aliow up o en we The new gambling manager's license effective (check one): � TY�e day after the current gambling man - e�. �� expires (for example, if the current gambling IScense exoires 7l31/96, the new gambiing manager's license 6ecomes effective on 8/1/96, provided that alf appiication infortnation is complete). � When the appiication has been processed by the Gam- 6ling Control Board—the effective date wiil be the first day of the month. h10TE: The new gambling manager may not assume duties until heJshe has received a gambling manager's license From the Gambling Controt Board. � Termination of empioyment of gambling manager on �_�.��.�'� . NOTE: The new gambling manager may not assume duties until helshe has received the gambling managers Iicense from the Gambling Conttol Board. Signature of CE� � ti� NotarizedSignature fGhiefExecu6v fficer(CEO) Date: ! � � � � / Notary Public Information. Notary Pubiic Seai must be current and correct; seal may not be altere,�. Subscrib and swom to before me this �I day of ^^ .�n^^—^^PA' ?q^n"h - //, .� �`..'� DELIA M. K � q�-14' �� l ,�p ° � ' � � J Boan �1 e Lic # �'� uence # wt Paid� � ck # 1 `f' ` �IS �P ¢'� � ��. \ \ \ �. , ,.� r Z..r,w,n r i Checkoneoftheboxes: � Male � Femaie l� � �^ iq ,��?� ��a 3 �� _� ��, � 1.V_IS'�/ �' �--�. "1- � �7l<✓� -�^1�_`'�(Q . W C (tL�(A- �' �-b'el� �w'/�M,�'\f.O[1a��4l� ��.� �(SG�I�.'T l�f.R+�. iv Q.r.yL�„g� /�v.^/\�. O-4A.m-A-^ C� /3.J-e. �ri2L"Y� �- K-c _�/� /� G � ��' OJ:I Wd-�J Gambling Manager Aj��lication (continue Affidavit and Consent � I, (print name) 3 C�Y h GY A. 1� under oath state that 1 have never: �. been convicted oY a felony or a cnme involving gam- bling; 2. committed a violation of faw or Board rule that resulted in the revocation of a license issued by the Board within five years before the date of the ficense application; 3. been convicted of a criminal violation invoiving fraud, theft, tax evasion, misrepresentation, or gambling; 4. been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii) making tenoristic threats. 5. been connected with nor engaged in an iilegai busi- ness; 6. owed $500 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 within the past two years; 8. faited to fife, after demand, tax retums required by the commissioner of revenue. in addition, l understand, agree, and hereby irrevocabiy consent that suits and actions relafing to the subject mat- terof the attached gambling manager4icense application, or acts or omissions arising from such applica6on, may 6e commenced against me or my organization and ! wili accept the service of process in any court of competent jurisdiction in Minnesota by service on the Minnesota Secreiary of State of any summons, process, or pieading 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 criminai and tax background check or review and to share the results with the Gambling Contro! Board. Fai)ure to provide required information or providing faise or misleading !.^.PC�f.^i3 may , in [he deniai or revocation of the license. FURTNER AFf1ANT SAYETH NOT, except that this A�davit and Consent Statement are submitted in support of the application for a gambfing manager license from the Gamblinq Controi Board. Signature of Gambting Manager Appiicant � G:�1 � ma� Notarized Signature otAppliwnt �o �� - �77 �i�-l4 � LCf2A�2 �'g � .siss' Page 2 of 2 . -� •�` 7his publication will be made available in alternative format (i.e. farge print, Braiile) upon request. If you use a TTY, you can call us using the Minnesota Refay Service at 1-800-627-3529 and ask them to piaCe a caii to (6i2) 639-4000. The i�formation requested on this form will be used by the Gambiing Controi Board (Board) to determine your compliance with Minnesota statutes and rules governing lawful gambling activities. All of the infor- mation that you supply on this form wili become public information when received by the Board. The information requested on this form (including any � attachments) wifl be used by the Board to determine your qualifications to be invotved in lawfui gambling aCtivities in Minnesota, and to assist the Board in 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- S;loiiGi�� :ilc ° uGaiu iu'ay ��vi uc 84iE iu G6ic�iuill6 y/OUf qualifications and, as a consequence, may refuse to issue you a license. if you supply the information required, the Board wili be able to process your appli- cation. Your name and address wiii be public information when received by the Board. Aif the other information about you that you provide will be private data until the Board issues your license. When the Board issues your--'� license, afl of the information you have provided to the Board in the process of applying for your ficense will become puh(ic excepf for your social secu rity 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 applying for a license remains private, with the exception of yaur name and address, which wiil remain pubiic. Private data about you is avaifabie onfy to the foliow- ing: Board members, staff of the Soard whose work assignment requires that they have access to the information; the Minnesota Department of Pubiic Safety; the Minnesota Atforney General; the Minne- sota Commissioners of Administration, Finance, and Revenue; the �egisiative Auditor; nationai and inter- n=t;�na� ga�� liny �eyu{aiory agencies; anyone pur- suant to couR order; other individuals and agencies that may be specifically authorized by state or federal law to have access to such information; individuais 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 Pubiic information. Notary Pub�ic Seai must be curtent and corcect; seal may not be altered. Subs i nd sworn to 6efore me this �� day o �._. _. „-,� , 1 9 � -� _. --�-