State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

LICENSE APPLICATION TYPE: (Please check all licenses for which you are applying) *Used gambling devices are those manufactured five or more years ago.

A. Manufacturer:

1. Manufacturer of 100 or fewer new devices

2. Manufacturer of more than 100 new devices

B. Distributor:

1. Distributor of 100 or fewer used devices

2. Distributor of more than 100 used devices

3. Distributor of 100 or fewer new devices

4. Distributor of more than 100 new devices

C. Testing Laboratory

(Fee $5,000 per year)

(Fee $7,500 per year)

(Fee $1,500 per year)

(Fee $2,000 per year)

(Fee $5,000 per year)

(Fee $7,500 per year)

1. Class III gaming

State Zip Code

Federal I.D. Number

State Zip Code

Federal I.D. Number

Name of Business

Address

City

Country

Phone Number

Website

Other Business Name

Address

City

Country

Phone Number

Website

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Note: Licenses EXPIRE at midnight on December 31st of each year.

(Fee $5,000 per year)

State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

BUSINESS CLASSIFICATION (select the appropriate box)

Corporation

Date of Incorporation:

Check type of Corporation:

Subchapter S Corporation

Publicly Traded Corporation

Closely Held Corporation

State/Province of Incorporation: Country:

Partnership (attach copy of the partnership agreement)

Sole Proprietorship

Non-Profit/Government Partnership

LICENSING HISTORY

During the past year has this company been licensed or applied for a license by any government agency for the purpose of gambling? YES NO

If yes, provide/attach the following information: All licenses applied for or issued by a federal, state or local agency. The date of issuance and expiration of each license. If any license application was denied, or a gambling license was suspended, canceled, or subject to any other licensing act other than issuance or renewal please provide the date and full explanation of the action.

LEGAL PROCEEDINGS:

During the past year has the company ever filed or been involved in a bankruptcy (other than as a creditor) or been charged with any criminal violation related to gambling? YES NO

If yes, explain in detail:

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State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

During the past year has the applicant ever been a party to a civil proceeding where it has been alleged to have been engaged in an unfair or anti-competitive business practice, a securities violation, or false or misleading advertising? YES NO

If yes, explain in detail:

During the past year has the applicant ever been involved as a party to a judicial or administrative action alleging violation of statute or rule relating to unfair labor practices, discrimination, or gambling?

YES NO

If yes, explain in detail:

During the past year has the applicant ever commenced an administrative or judicial action against a governmental regulator of gambling?

YES NO

If yes, explain in detail:

During the past year has the applicant ever failed to satisfy any judgement, decree, or order of an administrative or judicial tribunal? YES NO

If yes, explain in detail:

During the past year has the applicant ever been delinquent in filing a tax report or remitting a tax imposed by any governmental agency? YES NO

If yes, explain in detail:

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State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

RECORD KEEPING

Where are the financial books and records for this business kept? Address (physical location)

Who maintains these records? Name/Firm

Who prepares the tax returns, government forms, and reports? Name/Firm

LIST THE FINANCIAL INSTITUTIONS IN WHICH THE BUSINESS MAINTAINS OPERATING AND INVESTMENT ACCOUNTS.

Institution Address PhoneNumber Account Number

LIST THE SOURCE(S) AND AMOUNTS OF ALL OUTSTANDING BUSINESS LOANS OR REFINANCING.

Please attach supporting documents showing the terms of each financing arrangement.

Creditor Name Creditor Address Loan Amount Loan Number

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Contact Phone Number

Contact Phone Number

Contact Phone Number

State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE THE INFORMATION REQUESTED BELOW CONCERNING ANY INDIVIDUAL/PARTNERSHIP NOT ALREADY ON FILE WITH THE DIVISION:

Sole proprietorship

Limited and general partners (includes any government partners)

All shareholders in Sub-Chapter S and Closely Held Corporations

All shareholders owning 5% or more of the stock either directly or indirectly

All corporate officers and directors (includes non-profit)

Any person(s) holding an option to purchase the business

Legal Name Address Title Date of Birth SSN/

Gov’t ID #

*Each of the above individuals must submit a personal history statement with this form.

PLEASE PROVIDE THE NAME(S) AND ADDRESS(S) OF ANY HOLDING CORPORATION, SUBSIDIARY, OR AFFILIATE OF THE APPLICANT.

Name Address Relationship to Company Nature of Business

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PercentOwned

State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

PLEASE PROVIDE THE FULL NAME AND ADDRESS FOR EACH PERSON WHO HAS A RIGHT TO SHARE IN THE PROFITS OF THE BUSINESS.

Please include assignee, landlords, or persons to whom an interest or share of the profits has been pledged.

IDENTIFY ANY PERSON LISTED ABOVE THAT HAS A FINANCIAL INTEREST IN ANY OTHER GAMBLING ACTIVITY.

Name Business Address

PROVIDE THE NAMES OF ALL EMPLOYEES WHO ARE EMPLOYED IN GAMBLING RELATED POSITIONS AND INDICATE WHETHER THEY ARE A SALARY OR COMMISSION EMPLOYEE:

Name Position Location of Employment Salary orCommission

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Reason for Participation in ProfitsName Address

State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

DO YOU MAINTAIN AN OFFICE IN MINNESOTA?

YES NO

If “NO”, please read and sign the following irrevocable consent. If yes, provide the following information:

City State Zip Code Phone Number

IRREVOCABLE CONSENT

I am providing my irrevocable consent in agreeing that suits or actions related to the subject matter of the application, or acts or omissions arising from it, may be commenced in a court of competent jurisdiction in this state by service on the Secretary of State of any summons, process, or pleadings, authorized by the laws of the State of Minnesota. I also agree that any application for renewal of this license constitutes renewal of this consent agreement.

(Signature)

____________________________________ (Printed Name)

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Name of Manager

Street Address

____________________________________ ________________ (Date)

State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

ATTACH THE FOLLOWING DOCUMENTS TO THIS FORM:

1. Copy of most recent financial statement or most recent Federal and State Tax returns.2. If involved with a partnership or corporation and this has changed in the past year, please provide:

a. Articles of incorporationb. List of officers and board of directors or partnersc. List of stockholdersd. Partnership agreement

3. Personal history statements4. Cashiers check or money order for the license fee(s) and surcharge(s).

I certify that all statements made by the applicant in this document are true, complete and correct to the best of my knowledge and belief and are made by me in good faith. I also understand that an investigation will be conducted to insure the applicant meets the criteria for a license as established by Minnesota state law and department regulations. By signing this application I am also agreeing to pay for all costs incurred by the department in the conducting of an investigation of this application for a license.

Signature ______________________________________ Date _________________

(If a corporation, signer must be a corporate officer.)

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State of Minnesota Alcohol & Gambling Enforcement Division

445 Minnesota Street, Suite 1600 St. Paul, MN 55101

(651) 201-7500

AUTHORITY TO RELEASE INFORMATION

I, , authorize and grant my consent to permit any law enforcement agency, and any

other person, business or agency deemed necessary, to release any information requested by any identified law

enforcement officer of the Minnesota Department of Public Safety, Alcohol and Gambling Enforcement

Division.

___________________________________ ___________________________ _____________ Signature Title Date

Sworn and subscribed before me this

______ day of _____________, _____

Notary__________________________

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(If a corporation, signer must be a corporate officer.)

Business Name

This information is for the express purpose of determining my eligibility for a gambling license issued under the

authority of Minnesota State Statutes.

________________________________________________________

Business Name

MINNESOTA STATE STATUTE

299L.07 GAMBLING DEVICES. Subd. 8.License actions. (a) The commissioner may not issue or renew a license under this chapter, and shall revoke a license under thischapter, if the applicant or licensee, or a director, officer, partner, governor, person in a supervisory ormanagement position of the applicant or licensee, an employee eligible to make sales on behalf of the applicantor licensee, or direct or indirect holder of more than a five percent financial interest in the applicant or licensee:(1) has ever been convicted of a felony, or of a crime involving gambling;(2) has ever been convicted of (i) assault, (ii) a criminal violation involving the use of a firearm, or (iii) makingterroristic threats;(3) is or has ever connected with or engaged in an illegal business;(4) owes $500 or more in delinquent taxes as defined in section 270C.72;(5) had a sales and use tax permit revoked by the commissioner of revenue within the past two years;(6) after demand, has not filed tax returns required by the commissioner of revenue; or(7) had a license or permit revoked or denied by another jurisdiction for a violation of law or rule relating togambling.The commissioner may deny or refuse to renew a license under this chapter, and may revoke a license underthis chapter, if any of the conditions in this subdivision is applicable to an affiliate of or a direct or indirectholder of more than a five percent financial interest in the applicant or licensee.(b) The commissioner may by order deny, suspend, revoke, refuse to renew a license or premises permit, orcensure a licensee or applicant, if the commissioner finds that the order is in the public interest and that theapplicant or licensee, or a director, officer, partner, person in a supervisory or management position of theapplicant or licensee, or an employee eligible to make sales on behalf of the applicant or licensee:(1) has violated or failed to comply with any provision of this chapter, chapter 297E, or 349, or any rule adoptedor order issued thereunder;(2) has filed an application for a license that is incomplete in any material respect, or contains a statement that,in light of the circumstances under which it was made, is false, misleading, fraudulent, or a misrepresentation;(3) has made a false statement in a document or report required to be submitted to the director, thecommissioner, or the commissioner of revenue, or has made a false statement in a statement made to thedirector or commissioner;(4) has been convicted of a crime in another jurisdiction that would be a felony if committed in Minnesota;(5) is permanently or temporarily enjoined by any gambling regulatory agency from engaging in or continuingany conduct or practice involving any aspect of gambling;(6) has had a gambling-related license revoked or suspended, or has paid or been required to pay a monetarypenalty of $2,500 or more, by a gambling regulator in another state or jurisdiction, or has violated or failed tocomply with an order of such a regulator that imposed those actions;(7) has been the subject of any of the following actions by the director or commissioner: (i) had a license underthis chapter denied, suspended or revoked, (ii) been censured, reprimanded, has paid or been required to pay amonetary penalty or fine, or (iii) has been the subject of any other discipline by the director;(8) has engaged in conduct that is contrary to the public health, welfare, or safety, or to the integrity ofgambling; or(9) based on the licensee's past activities or criminal record, poses a threat to the public interest or to theeffective regulation and control of gambling, or creates or enhances the danger of unsuitable, unfair, or illegalpractices, methods, and activities in the conduct of gambling or the carrying on of the business and financialarrangements incidental to the conduct of gambling.

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