98-229Council File# Q �ZZ9
Ordinance $
RESOLUTION
Presented By
Re£erred To
CITY OF SAINT PAUL, MINNESOTA
Green Sheet # LP60029
2�
Committee: Date
RESOLVBD:
1 That application (ID #19980000504) for a Gambling Manager License(s)
2 by SHIRLEY MUNZ DBA MINNESOTA BRASSfMICHAEL'S at 1179 7TH ST
3 E be and the same is hereby approved.
Yeas xavs absent Requested by Department of:
Adoption Certified by council secretary
By:
APF
Bye
Office of License, Inspections and
Environmental Protection
Sy: �rb`� 'µAf""''`-�� 'Y ' J " 1"p"�g.n-/
Form Approved by City Attorney
By: �/`h An .J �
Approved by Mayor £or Submission ta
Council
By:
Adopted by Council: Date �,,.� ���
DEPARTMENT/OFFICHCOUNGL DA7E INRU7ED �� _ Z � /
uEP`u�'"° GREEN SHEET No. LP60029
ONTACT PERSON & PHONE
eanave,a m�mumn
UNTFiER WILLIAM (BILL)
{61� 2669132 � �, A �
UST BE ON COUNCIL AGENDA BY (DATE) � _
3-25-98 �f�Wt � �R�°'�'
ROIITC�G
OR�ER
TOTAL# OF SIGNATURE PAGES (CLIP ALL LOCATIOTJS FOR SIGNATURE)
ACTION REQUESTED:
CauicHepprWaloftliefdlavingGameappi'�cation: Licerse#1998WW504,forSHIRLEYMU�P,DoingBUSit�essASMINNESOTABRASSIMICHAEL'S,
at 1179 7TH ST E� k�dud(ng the fdbwi�7 business type(s): Gambling Manager.
RECOMMENDATIONS: Approve(A) Reject(R) ERSONAlSERVtcE cAN7RACiS AAJS7 MisWER iHE FOLLOW�NCi WEST10NS:
1. llastluspe�saMrtneverwo�kedunderacordracttatdusdePaAment?
,_ PLANNING COMMISSION Yes NO
__ CIB COMMITTEE 2. H� ttus persoMitm ever 6een a cay employee7
GIVIL SVC CINN, �S �
a. ooes this persorJfirm possess a s�an � rrormalN c�e� M=m curretN c�Yy emp�weea
YES NO
4. Is ihis perso�rtn e targeted vendoR
YES NO
Explain all yes answeB on separate sheet aMl attach to green sheet
INITIATING PROBI.EM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why):
Requesting Council approval for Shirley Munz DBA Minnesota Bwss for a Gambling Managefs license ffi Michael's, t 179 7th SL E.
ADVANTAGES IF APPROVED: � �� F �?'; ` ,..
�
�R 1 �.19
tSADVANTAGESIFAPPROVED:
DISADVANTAGES iF NOT APPROVED:
TOTAL AMOUNT OF TRANSACTtON $ COSTlREVENUE SUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE qCTMN NUMBER
FINANCIAL INFORMATION:
(fXPLAIN)
�I 5-22�
STATEOFMINNESOTA FOR BOARD IISE ONL�
Eyst GAMBLING CONTROL BOARD AMT . PAID
GAMBLING MANAGER LICENSE RENEWAL APPLICATION CHECK #
DATE
LG212GTvfRPRIN?ED: 10l13l47 INITIALS
Incomplete, false, ar misleading application information may result in denial of a license.
LICENSE NUMBER: G00444 001 EFFECTIVE DATE:04/Oi/96 EXPIIZATION DATE: 03/31/98
ORG�\TZATION INFORMATION
NAME OF ORGANIZATION: Minn Brass St Paul
CEO NAME: Gavin Bumham
GAMBLING MANAGE;R INFJRNSATION
Shirley B Munz
3606 E 70th St
Znver Grove Heights MN 55076
DATE OF BIRTH: 11/03/35
SEX: F
SOCIAL SECURITY NUMBER: 388-40-6875
DAYTIME PHONE NL3MBER: 612-552-3129
MEMBER SINCE: 06/Ol(82
EDUCATION INFORMATION
MOST RECENT CObITINUING EDUCATION CLASS YOU ATTENDED: 12/04l96
BOiVD IIVFORMATTON
BOND COMPANY NAME: United Fire & Casual BOND NUMBER: 5184060
GAMBLING MANAGER CHANGE
When your organization is using this renewal application to change its gambling manager, complete one of the following sections:
Emergency Change - Allow up to five working Other Change - Allow up to ten weeks for processing
days for processing The new gambling manager's license should become
The chief executive o�cer, by signing below, effective (check one):
affirms that the emergency application is due
to tUe following reason (Check one and fiil in date): The day aRer the cuaent gambling manager's license expires
(for ezample, if the current gambrmg manager's Iicense expire
Death o€� ' _%_/� 07/31l97 the new gambling manager's license becomes
— ��r.,,:bUV ,�t �RA 3�3 ^: effective on O8/Ol/97, provided that all appiication informatio
_DisabIlity��'���2ger on_/_/, is complete).
,� 0 ,,,,�,�, r; , t • • .. _When the application has been processed by the Gambling
^ Termination.o�emploqment of gambling Control Boazd--the effective date will be the first day of
manager on_/,/_ the month.
Note: A New gambling manager may not assume duties until helshe has received the gamhling manager's license from the
Gambiing Control Boazd.
The current chief executive o�cer of your organization must sign this application in che presence of a notary
SIGNAT[JKE OF CFIIEF EXECUTIVE OFFICER (CEO)
No[arized Signature of CEO
Date 10-19-9�
f �f���ll SG�
Notary Public Informatioa. Notary Public Seal
must be current and correct; seal may not be altered.
Subscribed and swom to before me this ( 4
day of ��-. ,19,
Notary Public
on Bacl
9��ZZ9
LG212G
a
Page 2 .
Gambling Manager Renewai Application (continued)
�davit and Consen Statement:
I,(print aame) C; h� r �e .i � � u» L ,under oath state that I have never:
1. been convicted of a felony or crime involving gambling;
2. committed a violation of law or Boazd rule that resulted
in the revocation of a license issued by the Board within
five yeazs before the date of the licease application;
3. been convicted of a criminal violation involving fraud,
theft, tax evasion, misrepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving die use of a firearm, or (iii) making tetroristic
threats;
I do not owe $500 or more in delinquent taxes as defined in section 270.72.
5. been, or am now, connected with nor engaged in
an illegal business;
6. fiad a sates and use taz pernnt revoked by the commissic
of revenue within the past two years;
7. after demand, failed to file, tax returas cequued by the
commissioner of revemie.
In addition, 1 understand, agree, and hereby irrevocably consent that suits and actions relaYmg to the subject matter of the attached
gambling manager license application, or acts or omissions azising from such application, may be commenced against me or my
organiza[ion and I will accept the service of process in any court of competent jurisdiction in Minnesota by service on the
Minnesota Secretary of State of any summons, process, or pieading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Depaztments of Public Safety and Revenue to wnduct a criminal and taz
background check or review and to shue the results with the Gambling Control Boazd.
Failure to provide required information or providing false or misleading information may result in the denial or revocation of the
license.
FURTHER AFFIANT SAYETH NOT, ezcept that this Affidavit and Consent Statement aze subtnitted ia support of the application for a
gambling manager ]icense from the Gambling Control Board.
SIGNATURE OF GAMBLING MANAGER APPLICANT
Notarized Signanlfe of Applicant
Notary Public Information. Notary Public Seal
must be current and conect; seal may not be altered.
Subscribed and sworn to before me this �
day of n;t ,19 S�_.
Date / 0 ' l /�' / 7
Public
This pubiication will be made available in altemative fortnat (i.e. large pcin[. Bnille) upon reques[. If you us a'S�ou can
Relay Service at (bl2) 297-5353 or 1•800-627-3529 and ask them to place a call w(612) 639-0000.
The infottnadon reques[ed on this fortn will be used by the Gambling Control Boaid (Boacd) to dete�mine your compliance with Minnewta stam[es and Iules goveming
lawtui gambling activities. All of the informauon that you supply on this form will become public informauon when [eceived by rhe Hoard.
You att tequittd to provide your socia! securiry numbor on this form. Your socia! seeu»ry number wi41 be used w demcmine your wmpliance with the tax laws of
Minnewm. Autfwrizatiun for requiring you[ wcia! :ecuriry number is found at 42 U.S.C. 405(c)(i).
The information requesred on [his fonn (including any attachmena) wil! be used by tt�e Board w dekrm'u�e your quali6cadons m be imolved in lawful gamb�eng
activities in Minnesota, and to assis[ the Board in conduc[ing a background invesugaaon of you.
You have the right to refuse to supply tfie infolmauon requested; howevet, if you refuse to supply ffiis infortnation, the Boaid may not be able m dececmine you�
quatificarions and, as a cansequence, may ee[use to issue you a licenu. If you wpply the infoemadon wqui�ed, the Boant will be able [o process your appiicauon.
Your name and address will be public informadon when received by the Boatd. All the other infortnadon about you that you provide will be private dap until the Board
issues your license. When the Board issues your license, alI of the informaaon you have p`ovided to tbe Board in the process of applying for your licenu will
become pubtic except for your social securiry number, which remains privaee.
If ihe Boatd dces na iss�e yon a license, all the infom�ation you have provided in the ptoceu of applying for a license cemainc private, with the excepuon of your name
and address, which will remain public. ' '
_.,,,�.._..� J..... �...�.
Privaee daW about you is avulable qi co�h €ql�qw.ing: Boald membecs, staff of [he Board whose work assignmrnt requircs that thry Aave access W[he infolmation;
the Minnesoq Depamnenc�d€P.u��td�,�,MmneS}� Attomey Geneml; Ne Minnesota Commissioners of Adminisvauon, Finance ar�d Revecme; the Legislative A�
nationat and intemaao�}1 garyt��{ggylNpcy9yA0ait�; a oue putsuant ro coutt order, other individuaSs and agrncies that tnay be speci�cally suthorized by state
or fedemi iaw to have 3cesslrsna5 in4waadoe�•i�idu� agene�es For which law oc legal otdes audtortzes a new use or sha[ing of the informafioa af[er this
noeice is given: you: am'i anyone a�A yoeF�LsRYE�f� ^�onsent.
._.- ....�...�.... ..
Council File# Q �ZZ9
Ordinance $
RESOLUTION
Presented By
Re£erred To
CITY OF SAINT PAUL, MINNESOTA
Green Sheet # LP60029
2�
Committee: Date
RESOLVBD:
1 That application (ID #19980000504) for a Gambling Manager License(s)
2 by SHIRLEY MUNZ DBA MINNESOTA BRASSfMICHAEL'S at 1179 7TH ST
3 E be and the same is hereby approved.
Yeas xavs absent Requested by Department of:
Adoption Certified by council secretary
By:
APF
Bye
Office of License, Inspections and
Environmental Protection
Sy: �rb`� 'µAf""''`-�� 'Y ' J " 1"p"�g.n-/
Form Approved by City Attorney
By: �/`h An .J �
Approved by Mayor £or Submission ta
Council
By:
Adopted by Council: Date �,,.� ���
DEPARTMENT/OFFICHCOUNGL DA7E INRU7ED �� _ Z � /
uEP`u�'"° GREEN SHEET No. LP60029
ONTACT PERSON & PHONE
eanave,a m�mumn
UNTFiER WILLIAM (BILL)
{61� 2669132 � �, A �
UST BE ON COUNCIL AGENDA BY (DATE) � _
3-25-98 �f�Wt � �R�°'�'
ROIITC�G
OR�ER
TOTAL# OF SIGNATURE PAGES (CLIP ALL LOCATIOTJS FOR SIGNATURE)
ACTION REQUESTED:
CauicHepprWaloftliefdlavingGameappi'�cation: Licerse#1998WW504,forSHIRLEYMU�P,DoingBUSit�essASMINNESOTABRASSIMICHAEL'S,
at 1179 7TH ST E� k�dud(ng the fdbwi�7 business type(s): Gambling Manager.
RECOMMENDATIONS: Approve(A) Reject(R) ERSONAlSERVtcE cAN7RACiS AAJS7 MisWER iHE FOLLOW�NCi WEST10NS:
1. llastluspe�saMrtneverwo�kedunderacordracttatdusdePaAment?
,_ PLANNING COMMISSION Yes NO
__ CIB COMMITTEE 2. H� ttus persoMitm ever 6een a cay employee7
GIVIL SVC CINN, �S �
a. ooes this persorJfirm possess a s�an � rrormalN c�e� M=m curretN c�Yy emp�weea
YES NO
4. Is ihis perso�rtn e targeted vendoR
YES NO
Explain all yes answeB on separate sheet aMl attach to green sheet
INITIATING PROBI.EM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why):
Requesting Council approval for Shirley Munz DBA Minnesota Bwss for a Gambling Managefs license ffi Michael's, t 179 7th SL E.
ADVANTAGES IF APPROVED: � �� F �?'; ` ,..
�
�R 1 �.19
tSADVANTAGESIFAPPROVED:
DISADVANTAGES iF NOT APPROVED:
TOTAL AMOUNT OF TRANSACTtON $ COSTlREVENUE SUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE qCTMN NUMBER
FINANCIAL INFORMATION:
(fXPLAIN)
�I 5-22�
STATEOFMINNESOTA FOR BOARD IISE ONL�
Eyst GAMBLING CONTROL BOARD AMT . PAID
GAMBLING MANAGER LICENSE RENEWAL APPLICATION CHECK #
DATE
LG212GTvfRPRIN?ED: 10l13l47 INITIALS
Incomplete, false, ar misleading application information may result in denial of a license.
LICENSE NUMBER: G00444 001 EFFECTIVE DATE:04/Oi/96 EXPIIZATION DATE: 03/31/98
ORG�\TZATION INFORMATION
NAME OF ORGANIZATION: Minn Brass St Paul
CEO NAME: Gavin Bumham
GAMBLING MANAGE;R INFJRNSATION
Shirley B Munz
3606 E 70th St
Znver Grove Heights MN 55076
DATE OF BIRTH: 11/03/35
SEX: F
SOCIAL SECURITY NUMBER: 388-40-6875
DAYTIME PHONE NL3MBER: 612-552-3129
MEMBER SINCE: 06/Ol(82
EDUCATION INFORMATION
MOST RECENT CObITINUING EDUCATION CLASS YOU ATTENDED: 12/04l96
BOiVD IIVFORMATTON
BOND COMPANY NAME: United Fire & Casual BOND NUMBER: 5184060
GAMBLING MANAGER CHANGE
When your organization is using this renewal application to change its gambling manager, complete one of the following sections:
Emergency Change - Allow up to five working Other Change - Allow up to ten weeks for processing
days for processing The new gambling manager's license should become
The chief executive o�cer, by signing below, effective (check one):
affirms that the emergency application is due
to tUe following reason (Check one and fiil in date): The day aRer the cuaent gambling manager's license expires
(for ezample, if the current gambrmg manager's Iicense expire
Death o€� ' _%_/� 07/31l97 the new gambling manager's license becomes
— ��r.,,:bUV ,�t �RA 3�3 ^: effective on O8/Ol/97, provided that all appiication informatio
_DisabIlity��'���2ger on_/_/, is complete).
,� 0 ,,,,�,�, r; , t • • .. _When the application has been processed by the Gambling
^ Termination.o�emploqment of gambling Control Boazd--the effective date will be the first day of
manager on_/,/_ the month.
Note: A New gambling manager may not assume duties until helshe has received the gamhling manager's license from the
Gambiing Control Boazd.
The current chief executive o�cer of your organization must sign this application in che presence of a notary
SIGNAT[JKE OF CFIIEF EXECUTIVE OFFICER (CEO)
No[arized Signature of CEO
Date 10-19-9�
f �f���ll SG�
Notary Public Informatioa. Notary Public Seal
must be current and correct; seal may not be altered.
Subscribed and swom to before me this ( 4
day of ��-. ,19,
Notary Public
on Bacl
9��ZZ9
LG212G
a
Page 2 .
Gambling Manager Renewai Application (continued)
�davit and Consen Statement:
I,(print aame) C; h� r �e .i � � u» L ,under oath state that I have never:
1. been convicted of a felony or crime involving gambling;
2. committed a violation of law or Boazd rule that resulted
in the revocation of a license issued by the Board within
five yeazs before the date of the licease application;
3. been convicted of a criminal violation involving fraud,
theft, tax evasion, misrepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving die use of a firearm, or (iii) making tetroristic
threats;
I do not owe $500 or more in delinquent taxes as defined in section 270.72.
5. been, or am now, connected with nor engaged in
an illegal business;
6. fiad a sates and use taz pernnt revoked by the commissic
of revenue within the past two years;
7. after demand, failed to file, tax returas cequued by the
commissioner of revemie.
In addition, 1 understand, agree, and hereby irrevocably consent that suits and actions relaYmg to the subject matter of the attached
gambling manager license application, or acts or omissions azising from such application, may be commenced against me or my
organiza[ion and I will accept the service of process in any court of competent jurisdiction in Minnesota by service on the
Minnesota Secretary of State of any summons, process, or pieading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Depaztments of Public Safety and Revenue to wnduct a criminal and taz
background check or review and to shue the results with the Gambling Control Boazd.
Failure to provide required information or providing false or misleading information may result in the denial or revocation of the
license.
FURTHER AFFIANT SAYETH NOT, ezcept that this Affidavit and Consent Statement aze subtnitted ia support of the application for a
gambling manager ]icense from the Gambling Control Board.
SIGNATURE OF GAMBLING MANAGER APPLICANT
Notarized Signanlfe of Applicant
Notary Public Information. Notary Public Seal
must be current and conect; seal may not be altered.
Subscribed and sworn to before me this �
day of n;t ,19 S�_.
Date / 0 ' l /�' / 7
Public
This pubiication will be made available in altemative fortnat (i.e. large pcin[. Bnille) upon reques[. If you us a'S�ou can
Relay Service at (bl2) 297-5353 or 1•800-627-3529 and ask them to place a call w(612) 639-0000.
The infottnadon reques[ed on this fortn will be used by the Gambling Control Boaid (Boacd) to dete�mine your compliance with Minnewta stam[es and Iules goveming
lawtui gambling activities. All of the informauon that you supply on this form will become public informauon when [eceived by rhe Hoard.
You att tequittd to provide your socia! securiry numbor on this form. Your socia! seeu»ry number wi41 be used w demcmine your wmpliance with the tax laws of
Minnewm. Autfwrizatiun for requiring you[ wcia! :ecuriry number is found at 42 U.S.C. 405(c)(i).
The information requesred on [his fonn (including any attachmena) wil! be used by tt�e Board w dekrm'u�e your quali6cadons m be imolved in lawful gamb�eng
activities in Minnesota, and to assis[ the Board in conduc[ing a background invesugaaon of you.
You have the right to refuse to supply tfie infolmauon requested; howevet, if you refuse to supply ffiis infortnation, the Boaid may not be able m dececmine you�
quatificarions and, as a cansequence, may ee[use to issue you a licenu. If you wpply the infoemadon wqui�ed, the Boant will be able [o process your appiicauon.
Your name and address will be public informadon when received by the Boatd. All the other infortnadon about you that you provide will be private dap until the Board
issues your license. When the Board issues your license, alI of the informaaon you have p`ovided to tbe Board in the process of applying for your licenu will
become pubtic except for your social securiry number, which remains privaee.
If ihe Boatd dces na iss�e yon a license, all the infom�ation you have provided in the ptoceu of applying for a license cemainc private, with the excepuon of your name
and address, which will remain public. ' '
_.,,,�.._..� J..... �...�.
Privaee daW about you is avulable qi co�h €ql�qw.ing: Boald membecs, staff of [he Board whose work assignmrnt requircs that thry Aave access W[he infolmation;
the Minnesoq Depamnenc�d€P.u��td�,�,MmneS}� Attomey Geneml; Ne Minnesota Commissioners of Adminisvauon, Finance ar�d Revecme; the Legislative A�
nationat and intemaao�}1 garyt��{ggylNpcy9yA0ait�; a oue putsuant ro coutt order, other individuaSs and agrncies that tnay be speci�cally suthorized by state
or fedemi iaw to have 3cesslrsna5 in4waadoe�•i�idu� agene�es For which law oc legal otdes audtortzes a new use or sha[ing of the informafioa af[er this
noeice is given: you: am'i anyone a�A yoeF�LsRYE�f� ^�onsent.
._.- ....�...�.... ..
Council File# Q �ZZ9
Ordinance $
RESOLUTION
Presented By
Re£erred To
CITY OF SAINT PAUL, MINNESOTA
Green Sheet # LP60029
2�
Committee: Date
RESOLVBD:
1 That application (ID #19980000504) for a Gambling Manager License(s)
2 by SHIRLEY MUNZ DBA MINNESOTA BRASSfMICHAEL'S at 1179 7TH ST
3 E be and the same is hereby approved.
Yeas xavs absent Requested by Department of:
Adoption Certified by council secretary
By:
APF
Bye
Office of License, Inspections and
Environmental Protection
Sy: �rb`� 'µAf""''`-�� 'Y ' J " 1"p"�g.n-/
Form Approved by City Attorney
By: �/`h An .J �
Approved by Mayor £or Submission ta
Council
By:
Adopted by Council: Date �,,.� ���
DEPARTMENT/OFFICHCOUNGL DA7E INRU7ED �� _ Z � /
uEP`u�'"° GREEN SHEET No. LP60029
ONTACT PERSON & PHONE
eanave,a m�mumn
UNTFiER WILLIAM (BILL)
{61� 2669132 � �, A �
UST BE ON COUNCIL AGENDA BY (DATE) � _
3-25-98 �f�Wt � �R�°'�'
ROIITC�G
OR�ER
TOTAL# OF SIGNATURE PAGES (CLIP ALL LOCATIOTJS FOR SIGNATURE)
ACTION REQUESTED:
CauicHepprWaloftliefdlavingGameappi'�cation: Licerse#1998WW504,forSHIRLEYMU�P,DoingBUSit�essASMINNESOTABRASSIMICHAEL'S,
at 1179 7TH ST E� k�dud(ng the fdbwi�7 business type(s): Gambling Manager.
RECOMMENDATIONS: Approve(A) Reject(R) ERSONAlSERVtcE cAN7RACiS AAJS7 MisWER iHE FOLLOW�NCi WEST10NS:
1. llastluspe�saMrtneverwo�kedunderacordracttatdusdePaAment?
,_ PLANNING COMMISSION Yes NO
__ CIB COMMITTEE 2. H� ttus persoMitm ever 6een a cay employee7
GIVIL SVC CINN, �S �
a. ooes this persorJfirm possess a s�an � rrormalN c�e� M=m curretN c�Yy emp�weea
YES NO
4. Is ihis perso�rtn e targeted vendoR
YES NO
Explain all yes answeB on separate sheet aMl attach to green sheet
INITIATING PROBI.EM, ISSUE, OPPORTUNITY (Who, What, When, Where, Why):
Requesting Council approval for Shirley Munz DBA Minnesota Bwss for a Gambling Managefs license ffi Michael's, t 179 7th SL E.
ADVANTAGES IF APPROVED: � �� F �?'; ` ,..
�
�R 1 �.19
tSADVANTAGESIFAPPROVED:
DISADVANTAGES iF NOT APPROVED:
TOTAL AMOUNT OF TRANSACTtON $ COSTlREVENUE SUDGETED (CIRCLE ONE) YES NO
FUNDING SOURCE qCTMN NUMBER
FINANCIAL INFORMATION:
(fXPLAIN)
�I 5-22�
STATEOFMINNESOTA FOR BOARD IISE ONL�
Eyst GAMBLING CONTROL BOARD AMT . PAID
GAMBLING MANAGER LICENSE RENEWAL APPLICATION CHECK #
DATE
LG212GTvfRPRIN?ED: 10l13l47 INITIALS
Incomplete, false, ar misleading application information may result in denial of a license.
LICENSE NUMBER: G00444 001 EFFECTIVE DATE:04/Oi/96 EXPIIZATION DATE: 03/31/98
ORG�\TZATION INFORMATION
NAME OF ORGANIZATION: Minn Brass St Paul
CEO NAME: Gavin Bumham
GAMBLING MANAGE;R INFJRNSATION
Shirley B Munz
3606 E 70th St
Znver Grove Heights MN 55076
DATE OF BIRTH: 11/03/35
SEX: F
SOCIAL SECURITY NUMBER: 388-40-6875
DAYTIME PHONE NL3MBER: 612-552-3129
MEMBER SINCE: 06/Ol(82
EDUCATION INFORMATION
MOST RECENT CObITINUING EDUCATION CLASS YOU ATTENDED: 12/04l96
BOiVD IIVFORMATTON
BOND COMPANY NAME: United Fire & Casual BOND NUMBER: 5184060
GAMBLING MANAGER CHANGE
When your organization is using this renewal application to change its gambling manager, complete one of the following sections:
Emergency Change - Allow up to five working Other Change - Allow up to ten weeks for processing
days for processing The new gambling manager's license should become
The chief executive o�cer, by signing below, effective (check one):
affirms that the emergency application is due
to tUe following reason (Check one and fiil in date): The day aRer the cuaent gambling manager's license expires
(for ezample, if the current gambrmg manager's Iicense expire
Death o€� ' _%_/� 07/31l97 the new gambling manager's license becomes
— ��r.,,:bUV ,�t �RA 3�3 ^: effective on O8/Ol/97, provided that all appiication informatio
_DisabIlity��'���2ger on_/_/, is complete).
,� 0 ,,,,�,�, r; , t • • .. _When the application has been processed by the Gambling
^ Termination.o�emploqment of gambling Control Boazd--the effective date will be the first day of
manager on_/,/_ the month.
Note: A New gambling manager may not assume duties until helshe has received the gamhling manager's license from the
Gambiing Control Boazd.
The current chief executive o�cer of your organization must sign this application in che presence of a notary
SIGNAT[JKE OF CFIIEF EXECUTIVE OFFICER (CEO)
No[arized Signature of CEO
Date 10-19-9�
f �f���ll SG�
Notary Public Informatioa. Notary Public Seal
must be current and correct; seal may not be altered.
Subscribed and swom to before me this ( 4
day of ��-. ,19,
Notary Public
on Bacl
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Page 2 .
Gambling Manager Renewai Application (continued)
�davit and Consen Statement:
I,(print aame) C; h� r �e .i � � u» L ,under oath state that I have never:
1. been convicted of a felony or crime involving gambling;
2. committed a violation of law or Boazd rule that resulted
in the revocation of a license issued by the Board within
five yeazs before the date of the licease application;
3. been convicted of a criminal violation involving fraud,
theft, tax evasion, misrepresentation, or gambling;
4. been convicted of (i) assault, (ii) a criminal violation
involving die use of a firearm, or (iii) making tetroristic
threats;
I do not owe $500 or more in delinquent taxes as defined in section 270.72.
5. been, or am now, connected with nor engaged in
an illegal business;
6. fiad a sates and use taz pernnt revoked by the commissic
of revenue within the past two years;
7. after demand, failed to file, tax returas cequued by the
commissioner of revemie.
In addition, 1 understand, agree, and hereby irrevocably consent that suits and actions relaYmg to the subject matter of the attached
gambling manager license application, or acts or omissions azising from such application, may be commenced against me or my
organiza[ion and I will accept the service of process in any court of competent jurisdiction in Minnesota by service on the
Minnesota Secretary of State of any summons, process, or pieading authorized by the laws of Minnesota.
By signature of this document, the undersigned authorizes the Depaztments of Public Safety and Revenue to wnduct a criminal and taz
background check or review and to shue the results with the Gambling Control Boazd.
Failure to provide required information or providing false or misleading information may result in the denial or revocation of the
license.
FURTHER AFFIANT SAYETH NOT, ezcept that this Affidavit and Consent Statement aze subtnitted ia support of the application for a
gambling manager ]icense from the Gambling Control Board.
SIGNATURE OF GAMBLING MANAGER APPLICANT
Notarized Signanlfe of Applicant
Notary Public Information. Notary Public Seal
must be current and conect; seal may not be altered.
Subscribed and sworn to before me this �
day of n;t ,19 S�_.
Date / 0 ' l /�' / 7
Public
This pubiication will be made available in altemative fortnat (i.e. large pcin[. Bnille) upon reques[. If you us a'S�ou can
Relay Service at (bl2) 297-5353 or 1•800-627-3529 and ask them to place a call w(612) 639-0000.
The infottnadon reques[ed on this fortn will be used by the Gambling Control Boaid (Boacd) to dete�mine your compliance with Minnewta stam[es and Iules goveming
lawtui gambling activities. All of the informauon that you supply on this form will become public informauon when [eceived by rhe Hoard.
You att tequittd to provide your socia! securiry numbor on this form. Your socia! seeu»ry number wi41 be used w demcmine your wmpliance with the tax laws of
Minnewm. Autfwrizatiun for requiring you[ wcia! :ecuriry number is found at 42 U.S.C. 405(c)(i).
The information requesred on [his fonn (including any attachmena) wil! be used by tt�e Board w dekrm'u�e your quali6cadons m be imolved in lawful gamb�eng
activities in Minnesota, and to assis[ the Board in conduc[ing a background invesugaaon of you.
You have the right to refuse to supply tfie infolmauon requested; howevet, if you refuse to supply ffiis infortnation, the Boaid may not be able m dececmine you�
quatificarions and, as a cansequence, may ee[use to issue you a licenu. If you wpply the infoemadon wqui�ed, the Boant will be able [o process your appiicauon.
Your name and address will be public informadon when received by the Boatd. All the other infortnadon about you that you provide will be private dap until the Board
issues your license. When the Board issues your license, alI of the informaaon you have p`ovided to tbe Board in the process of applying for your licenu will
become pubtic except for your social securiry number, which remains privaee.
If ihe Boatd dces na iss�e yon a license, all the infom�ation you have provided in the ptoceu of applying for a license cemainc private, with the excepuon of your name
and address, which will remain public. ' '
_.,,,�.._..� J..... �...�.
Privaee daW about you is avulable qi co�h €ql�qw.ing: Boald membecs, staff of [he Board whose work assignmrnt requircs that thry Aave access W[he infolmation;
the Minnesoq Depamnenc�d€P.u��td�,�,MmneS}� Attomey Geneml; Ne Minnesota Commissioners of Adminisvauon, Finance ar�d Revecme; the Legislative A�
nationat and intemaao�}1 garyt��{ggylNpcy9yA0ait�; a oue putsuant ro coutt order, other individuaSs and agrncies that tnay be speci�cally suthorized by state
or fedemi iaw to have 3cesslrsna5 in4waadoe�•i�idu� agene�es For which law oc legal otdes audtortzes a new use or sha[ing of the informafioa af[er this
noeice is given: you: am'i anyone a�A yoeF�LsRYE�f� ^�onsent.
._.- ....�...�.... ..