Background Investigation Inquiry

State of Minnesota Department of Public Safety Alcohol & Gambling Enforcement Division 445 Minnesota Street, Suite 222 St. Paul, MN. 55101-5133 Background Investigation Inquiry (MN. Statute 349 - Lawful Gambling) 1.) Name of Business:2.) Business Address:street - CityStateZip3.) Telephone Number: () - - 4.) Federal I.D. # 5.) IS BUSINESS A:Corporation (mark appropriate box)Check type of Corporation:Date of Incorporation: Subchapter S Corporation Publicly Traded Corporation Closely held CorporationState of Incorporation:Partnership (attach partnership agreement) Sole proprietorship 6.) HAS THIS COMPANY EVER BEEN LICENSED BY ANY GOVERNMENTAGENCY FOR THE PURPOSE OF GAMBLING? (CIRCLE) Yes NoIf yes provide the following information for all licenses issued: date licensed; type of licenseheld; agency issuing license; and state or jurisdiction where license was issued. (use additional paper if necessary) MAN/DIS/349/5-97 American LegalNet, Inc. www.FormsWorkFlow.com (2) 7.) HAS THE COMPANY EVER HAD ANY ACTION TAKEN AGAINST A GAMBLINGLICENSE BY ANY AGENCY? (CIRCLE) Yes No If yes, explain and provide currentstatus. Fined Suspended Revoked Other Action (use additional paper if necessary) 8.) HAS THE COMPANY FILED OR BEEN INVOLVED IN BANKRUPTCY (OTHERTHAN AS A CREDITOR) OR BEEN CHARGED WITH A CRIMINAL VIOLATIONRELATED TO GAMBLING?If yes - explain and provide current status.yes no -- Bankruptcy yes no -- Criminal (use additional paper if necessary) 9.) OTHER LICENSINGHave you ever had a sales and use tax permit revoked or canceled?YESNOHave you ever had any other license or permit revoked, denied or canceled?YESNOHave you ever failed to pay and gambling tax to any regulatory agency?YESNOIf 223yes224 to any of the above, provide complete deatils below.(attach additional sheets if necessary) 10.) RECORD KEEPINGA.) Where are the financial books and records for this business kept?Who maintains these records?Who prepares the tax returns, government forms and reports? American LegalNet, Inc. www.FormsWorkFlow.com (3) B.) Does the applicant maintain an office within Minnesota?(Circle) Yes NoIf yes, answer the following questions:-- Mailing address of office:-- Street address of office: -- Name of manager: -- Telephone Number of office: () - -- 11.) LIST THE FINANCIAL INSTITUTIONS IN WHICH THE BUSINESSMAINTAINS OPERATING AND INVESTMENT ACCOUNTS.InstitutionAddressPhoneAccount Number (use additional sheets in necessary) 12.) LIST THE SOURCE(S) AND AMOUNTS OF ALL OUTSTANDING BUSINESSLOANS. PROVIDE THE FOLLOWING:CREDITORCREDITORLOANLOANNAMEADDRESSAMOUNTNUMBER (use additional sheets if necessary) American LegalNet, Inc. www.FormsWorkFlow.com (4) 13.) PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE THEINFORMATION REQUESTED BELOW CONCERNING: (use additional sheets if necessary)Sole proprietorship.Limited and general 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.Any person(s) holding an option to purchase the business.Legal Date of Social NameAddressTitleBirth Security #% Owned (use additional sheets if necessary)Each of these individuals must submit a Personal history Statement with this form. 14.) IDENTIFY ANY PERSON LISTED ABOVE THAT HAS A FINANCIAL INTERESTIN ANY OTHER GAMBLING ACTIVITY. Provide the name, activity or business and address.NameBusinessAddress (use additional sheets if necessary) American LegalNet, Inc. www.FormsWorkFlow.com (5) 15.) PROVIDE THE NAMES OF ALL EMPLOYEES HOLDING MANAGEMENTPOSITIONS:LegalAddressTitleDate ofSocialNameBirthSecurity # (use additional sheets if necessary)Each of these individuals must submit a Personal History Statement with this form. 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;a.) Articles of incorporationb.) List of officers and board of directors or partnersc.) List of stockholdersd.) Partnership agreement3.) Personal History Statements for each person listed in Section 15 I certify that all statements made by the applicant in this document are true, complete and correct tothe best of knowledge and belief and are made by me in good faith. I also understand that aninvestigation will be conducted to insure the applicant meets the criteria for a license as establishedby the Minnesota state law and department regulations. By signing this application I am alsoagreeing to pay for all costs incurred by the department in the conducting of an investigation of thisapplication for a license. SignatureDate(If a corporation, signer must be a corporate officer) American LegalNet, Inc. www.FormsWorkFlow.com State of Minnesota Department of Public Safety Alcohol & Gambling Enforcement Division AUTHORITY TO RELEASE INFORMATION I, , authorize and grant my consent to permitBusinessany law enforcement agency, and any other person, business or agency deemed necessary, torelease any information requested by any identified law enforcement officer of the MinnesotaDepartment of Public Safety, Alcohol and Gambling Enforcement Division.This information is for the express purpose of determining my eligibility for a gambling licenseissued under the authority of Minnesota State Statutes.NAME:(NAME OF BUSINESS)Signature:Title: (If a corporation, signer must be a corporate officer)Date:Sworn and subscribed before me this day of , 20Notary American LegalNet, Inc. www.FormsWorkFlow.com