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4 Minnesota lawful Gamblingp GamblingConol (LG20(R) lawful Gambling LicensIr e Renewal Appl-ication twWoqr1w Corrections should be made directly on this application SLI bmit one check for all renewal fees, payable to State of Minnesota Organization requirements: Current license term: 2/1/2007 to 1/31/2009 1. An organization license fee of $350 paid annually. Authorization: 102 g, Check this box if your organization qualifies for Organization: American Legion Post 513 New Brighton (651)631-1124 the waiver of the $iso 400 Old HlAy 8 NW, New Brighton, MN 55112 County: Ramsey organization license fee defined in MN statute CECT: Norbert Norris Stachowski 349.16 subd. 6 4605 7th St NE Columbia Heights, MN 55421 (651)631-1124 Treasurer: TomeL Ziesmr 3221 Edward 5 NE, St. Anthony, MN 554118 (612.)781-2294 Annual Goal for Charitab a Contributions`" Gambling Manager Requ rements: 1. A gambling manager lic rise fee of $100 paid annually. Gambling Manager Auth rization: GM -00.02-002 Current License Term: 2/1/2007 to 1/31/2009 Lawrence Anthony Schwal e 4 The individual listed is not renewing their license. We have enclosed a LG212 2168 Rice Creek Rd, New Brighton, MN 55112 application for the new applicant. (651)633-8847 Bon # 69508090 Note: The gambling manager duties may not be assumed by an individual until they are licensed by the Minnesota Company: Western Surety Gambling Control Board. Gambling Manager Affidavit and Consent Statement 1. I have never been convicted of a felony or a crime 0Involving gambling. 2. I have never committed a violation of law or Board rule that resulted in the revocation cf a license issued by the Board within five years before the date of the license application. 3. I have never been convicted f a criminal violation involving fraud, theft, tax evasic n, misrepresentation, or gambling. 4. I have never been convicted f (i) assault, (ii) a criminal violation involving the use of a rearm, or (iii) making terroristic threats. 5. I have never been, or am I n w, connected with or engaged in an illegal business. 6. I have never had a sales and use tax permit revoked by the commissioner of revenue wi hin the past two years. 7. I have never, after demand, failed to file tax returns required by the commissioner o revenue. 8. I do not owe $500 or more in delinquent taxes as defined in section 270.72. 9. I have been an active membE r of the organization for at least two years at the time Of OL r organization's initial license application, or have been an active member for at least the most recent six months prior to the effective date of our organization's license renewal. 10. I am not a gambling manag r or an assistant gambling manager for another organization. 11. I am not a lessor, a member of the lessor's immediate family or a person residing in the same household as the olessor, or an employee of a lessor of a premises where this rganization has a permit issued from the Board to conduct lawful gambling. 12. I am not involved directly or indirectly as a bingo hall owner, manufacturer. or distributor. 13. I am not the chief executive officer of this organization. 14. I am not the treasurer of this organization. 15. I was not an officer of an organization at a time when an offense occurred which caused that organization's license to be revoked. Background Check. By signature of this document, the undersigned authorizes the Departments of Public Safety and Revenue to conduct a criminal and tax background check or review and to share the results with the Gambling Control Board. Further, I understand, agree, and hereby irrevocably consent that suits and actions relating to the subject matter of this gambling manager license application, or acts or omissions arising from such application, may be commenced against me or my organization 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 pleading authorized by the laws of Minnesota. Failure to provide required information or providing false or misleading information may result in the denial or revocation of the license. Changes in the information submitted in this application will be submitted in writing no later than 10 days after the change has taken effect. I have read this application and declare that all information submitted " true, accurate, and compJ.dte. ignature, in ink, of gambling manager applic t Date: / Organization Renewal App Reprint: Report