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Gambling Devices Application - Minnesota

Gambling Devices Application Form. This is a Minnesota form and can be used in Alcohol And Gambling Enforcement Division Statewide .
 Fillable pdf Last Modified 1/27/2014
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MANUFACTURER AND/OR DISTRIBUTOR GAMBLING DEVICES APPLICATION LICENSE APPLICATION TYPE: (Please check all licenses for which you are applying) A. Manufacturer: 1. Manufacturer of 100 or fewer new devices 2. Manufacturer of more than 100 new devices (Fee $5,000 per year) (Fee $7,500 per year) 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 (Fee $1,500 per year) (Fee $2,000 per year) (Fee $5,000 per year) (Fee $7,500 per year) Note: Your license when issued will expire at midnight on December 31st of each year. Licensing Surcharge: $150.00 (for each type of license) INVESTIGATION FEE: (Applicants are required to pay the costs of the licensing investigation.) Applicants located within Minnesota: Applicants located outside of Minnesota: Initial Fee $1,500 Initial Fee $7,500 Applicants will be billed for additional fees for the costs of the licensing investigation as may be necessary. Name of Business Address City Country Phone Number Other Business Name Address City Country Phone Number Federal I.D. Number American LegalNet, Inc. www.FormsWorkFlow.com State Zip Code Federal I.D. Number State Zip Code BUSINESS CLASSIFICATION Corporation (mark appropriate box) Date of Incorporation Check type of Corporation: Subchapter S Corporation Publicly Traded Corporation Closely Held Corporation State of Incorporation Partnership (attach copy of the partnership agreement) Sole Proprietorship HAS THIS COMPANY EVER BEEN LICENSED BY ANY GOVERNMENT AGENCY FOR THE PURPOSE OF GAMBLING? YES NO If yes, provide 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. OTHER LEGAL PROCEEDINGS: 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: 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: American LegalNet, Inc. www.FormsWorkFlow.com 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: HAS THE APPLICANT EVER COMMENCED AN ADMINISTRATIVE OR JUDICIAL ACTION AGAINST A GOVERNMENTAL REGULATOR OF GAMBLING? YES NO If yes, explain in detail: 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: HAS THE APPLICANT EVER BEEN DELINQUENT IN FILING A TAX REPORT OR REMITTING A TAX IMPOSED BY ANY GOVERNMENT? YES NO If yes, explain in detail: RECORD KEEPING 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 LIST THE FINANCIAL INSTITUTIONS IN WHICH THE BUSINESS MAINTAINS OPERATING AND INVESTMENT ACCOUNTS. INSTITUTION ADDRESS PHONE ACCOUNT NUMBER LIST THE SOURCE(S) AND AMOUNTS OF ALL OUTSTANDING BUSINESS LOANS OR REFINANCING? Please provide supporting documents showing the terms of each financing arrangement. CREDITOR NAME CREDITOR ADDRESS LOAN AMOUNT LOAN NUMBER PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE THE INFORMATION REQUESTED BELOW CONCERNING: 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 Number Percent Owned 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. American LegalNet, Inc. www.FormsWorkFlow.com Name Address Relationship to Company Nature of Business 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. Name Address Reason for Participation in Profits IDENTIFY ANY PERSON LISTED ABOVE THAT HAS A FINANCIAL INTEREST IN ANY OTHER GAMBLING ACTIVITY. Name Business Address Remove 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 or Commission 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: Name of Manager Mailing Address American LegalNet, Inc. www.FormsWorkFlow.com Street Address City Phone Number State Zip Code 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 Date 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 please provide: a. Articles of incorporation b. List of officers and board of directors or partners c. List of stockholders d. Partnership agreement 3. Personal history statements 4. 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
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