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Background Investigation Inquiry MAN DIS 349 - Minnesota

Background Investigation Inquiry Form. This is a Minnesota form and can be used in Alcohol And Gambling Enforcement Division Statewide .
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State of Minnesota Department of Public Safety Alcohol & Gambling Enforcement Division 444 Cedar Street Suite 133 St. Paul, MN. 55101-5133 Background Investigation Inquiry (MN. Statute 349 - Lawful Gambling) 1.) Name of Business:_____________________________________________________ 2.) Business Address:_____________________________________________________ street _________________________ ________________ ________- ______ City State Zip 3.) 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 Corporation State of Incorporation:________________________ ________Partnership (attach partnership agreement) ________ Sole proprietorship 6.) HAS THIS COMPANY EVER BEEN LICENSED BY ANY GOVERNMENT AGENCY FOR THE PURPOSE OF GAMBLING? (CIRCLE) Yes No If yes provide the following information for all licenses issued: date licensed; type of license held; 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 GAMBLING LICENSE BY ANY AGENCY? (CIRCLE) Yes No If yes, explain and provide current status. _______ Fined _____________________________________________________ _______ Suspended _____________________________________________________ _______ Revoked ________ Other Action _____________________________________________________ _____________________________________________________ (use additional paper if necessary) 8.) HAS THE COMPANY FILED OR BEEN INVOLVED IN BANKRUPTCY (OTHER THAN AS A CREDITOR) OR BEEN CHARGED WITH A CRIMINAL VIOLATION RELATED TO GAMBLING? If yes - explain and provide current status. _______ _______ yes yes _______ no -- Bankruptcy _____________________________ _______ no -- Criminal _____________________________ (use additional paper if necessary) 9.) OTHER LICENSING Have you ever had a sales and use tax permit revoked or canceled? YES Have you ever had any other license or permit revoked, denied or canceled? YES Have you ever failed to pay and gambling tax to any regulatory agency? YES If "yes" to any of the above, provide complete deatils below. NO NO NO ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (attach additional sheets if necessary) 10.) RECORD KEEPING A.) 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 No If 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 BUSINESS MAINTAINS OPERATING AND INVESTMENT ACCOUNTS. Institution Address Phone Account Number (use additional sheets in necessary) 12.) LIST THE SOURCE(S) AND AMOUNTS OF ALL OUTSTANDING BUSINESS LOANS. PROVIDE THE FOLLOWING: CREDITOR NAME CREDITOR ADDRESS LOAN AMOUNT LOAN NUMBER (use additional sheets if necessary) American LegalNet, Inc. www.FormsWorkFlow.com (4) 13.) PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE THE INFORMATION 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 Name Address Title Date of Birth Social 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 INTEREST IN ANY OTHER GAMBLING ACTIVITY. Provide the name, activity or business and address. Name Business Address (use additional sheets if necessary) American LegalNet, Inc. www.FormsWorkFlow.com (5) 15.) PROVIDE THE NAMES OF ALL EMPLOYEES HOLDING MANAGEMENT POSITIONS: Legal Name Address Title Date of Birth Social Security # (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.) 2.) Copy of most recent financial statement or most recent Federal and State Tax returns. If involved with a partnership or corporation; a.) Articles of incorporation b.) List of officers and board of directors or partners c.) List of stockholders d.) Partnership agreement Personal History Statements for each person listed in Section 15 3.) I certify that all statements made by the applicant in this document are true, complete and correct to the best of 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 the 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 (If a corporation, signer must be a corporate officer) Date
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