Personal History Statement

State of Minnesota 445 Minnesota Street Suite St. Paul, MN 55101 (651)201-7500Personal History Statement Name: (Last) (First) (Full Middle) Other names used (include alias, maiden names, previous names) Social Security Number: Date of Birth:Place of Birth: (County) (State) State of Issue Driver License # Current Address: (Street) (City) (State) (Zip) Telephone # Home: Work: Past Residences: List of past residences from 18 (incl ude city, county, state, and dates, month and year). City County State From (Yr.) To (Yr.) (use additional sheets if necessary) Weight: Eye Color: (Please provide the following information) PHYSICAL DESCRIPTION: Height: Hair Color: Ch One: Citizen: U.S. Other: Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CRIMINAL HISTORY: A. Have you ever been arrested or detained? Yes No Have you ever been convicted of a crime? Yes No Have you ever been the subject of an indictment? Yes No No Have you ever been subpoenaed for testimony or appearance?Have you ever been pardoned for any criminal offense? No If 223yes224 to any of the above questions, provide the following information: -- Date of convi ction -- City and State where convicted -- Nature of offense -- Order of the court (Use additional sheets if necessary) B. Are you currently charged and awaiting resolution of any violation of the Law? Yes NoIf 223Yes224, provide the following information:-- Date of offense--Nature of offense--City and State where offense occurred (Use additional sheets if necessary) PREVIOUS GAMBLING LICENSES: A. Ha ve you ever been licensed or denied a license by any government agency for the purpose of gambling? -- Agency issuing license Yes No If 223Yes224, provide the following information: -- Date Licensed --Type of license held -- State where license was issued (use additional sheets if necessary) Page 2 of 5 Yes Yes American LegalNet, Inc. www.FormsWorkFlow.com B. Have you been finger printed for any purpose within the last year? Yes No If 223Yes224, provide the following information: --Date -- Reason for fingerprinting --Agency receiving the fingerprint cards -- State where license was issued (Use additional sheets if necessary) PREVIOUS EMPLOYMENT: (Include current employer) Please provide the following information concerning your employment history. This information is required for all employers since age 18. Name of Employer Employer222s Address From To (use additional sheets if necessary) OTHER LICENSING: Have you ever failed to file Federal or State income tax records? YES NO Have you ever had a sales or use tax permit revoked? YES NO Have you ever had any other license or permit revoked, denied or cancelled? YES NO Have you ever failed to submit reports or pay taxes to any gambling agency? YES NO Please completely explain any 223yes224 answers below. (use additional sheets if necessary) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Financial Interest in other gambling activities: Please indicate by answering the following questions whether or not you have financial interest in any other gambling activity or business: A.Types of interest held: YES NO Invested or loaned money, have an option to purchase, or have a contract YES NO 2. Have ownership interest in equipment being leased or otherwise provided to any gambling facilities. YES NO 3. Have an investment or ownership in any business i nvolved in any of the activities listed in A. 1 or A. 2. YES NO 4. Do you receive any revenue or payments or money from any person who is involved in the activities listed in question A. 1 or A. 2 or is the result ofthe operation of gambling? Please completely explain all 223yes224 answers: (Use additional sheets if necessary) I certify that all statements made by me in this document are true, complete and correct to the best of my knowledge and belief and are made by me in good faith. Signature of the Applicant Date Signed Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com AUTHORITY TO RELEASE INFORMATION I, , authorize and grant my consent to permit the Minnesota Alcohol & Gambling Enforcement Division, any law enforcement agency, and any other individual or agency deemed necessary, to release any information to any identified law enforcement officer of the Alcohol & Gambling Enforcement Division. This information is subject to the Minnesota Data Privacy Act and for the express purpose of determining my eligibility for a gambling license under authority of Minnesota State Statutes. Name: (Last) (Full Middle) Date of Birth: ocial Security Number: Page 5 of 5 State of Minnesota 445 Minnesota Street Suite St. Paul, MN 55101 (651)201-7500 Sorn and subscribed before me this day of , 20 Notary American LegalNet, Inc. www.FormsWorkFlow.com