Temporary Permit Application

State of Minnesota Department of Public Safety Alcohol & Gambling Enforcement Division 444 Cedar St., Suite 222 St. Paul, MN 55101 651-201-7507 Temporary Permit Application General Information: Permits issued through this application are intended to allow manufacturers and distributors of gambling devices to display their products in Minnesota. Manufacturers and distributors licensed in Minnesota are not required to have this permit. This permit is for display purposes only and does not authorize the applicant to engage in sales activity. To engage in sales, the applicant must be licensed by the Alcohol & Gambling Enforcement Division. The permit is limited to the dates of the event. Applicants for the permit are not to bring the devices into Minnesota more than 72 hours before the event and are to have the devices removed from Minnesota within 72 hours after the event has ended. 1. Purpose for displaying the gambling device: (Please circle) a. Trade Show b. Convention or Conference c. Other: ____________________________________________________________ 2. Applicant: a. Business Name: ____________________________________________________ Address: __________________________________________________ Telephone: ________________________________________________ b. Provide the following information about the person who is responsible for the device(s) while in Minnesota. Name:____________________________________________________________ Address:__________________________________________________________ Telephone: ________________________________________________________ 3. Event Information: Location of Event: __________________________________________________ Name of Event: ____________________________________________________ Dates of Event: _____________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 4. Transportation of device(s): a. Method of Shipment: (Please circle) air truck rail other:_____________________________________ b. Date shipped to Minnesota: ___________________________________________ c. Name of Common Carrier: ___________________________________________ d. Date devices are to be removed from Minnesota: __________________________ 5. Description of device(s) to be brought into Minnesota: (Attach additional sheets as necessary): Type of Device Make Model Serial Number 6. Storage of Devices: If device will be stored at other than the site of the event, provide the address and name of business where the device will be stored. a. Name of business (where applicable): ___________________________________ b. Complete address: __________________________________________________ __________________________________________________________________ 7. Compliance with Federal Law: Attach copy of letter from the U.S. Department of Justice confirming registration with that agency. 8. Attachments: a. Permit fee: $100.00 (cashiers checks or money orders only, personal or business checks are not acceptable). b. Copy of U.S. Department of Justice registration letter. The applicant for a temporary permit acknowledges the Alcohol & Gambling Enforcement Division has been given the authority to inspect gambling devices to insure compliance with Minnesota state laws. _______________________________________________________________________ Signature Position or Title Date ________________________ Print Name American LegalNet, Inc. www.FormsWorkFlow.com