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Personal History Statement - Minnesota

Personal History Statement Form. This is a Minnesota form and can be used in Alcohol And Gambling Enforcement Division Statewide .
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State of Minnesota Alcohol & Gambling Enforcement Division 444 Cedar Street, Suite 133 St. Paul, Mn. 55101-5133 Tele:651-296-6159 Personal History Statement Name: (Last) (First) (Full Middle) Other Names Used (Include Alias, Maiden Names, Previous Married Names) Date of Birth: Place of Birth: (City) (State) Social Security Number:______________________ (County) Driver License No. _____________________________ State of Issue: Position you hold with the applicants business:___________________________________ (Please provide the following information) PHYSICAL DESCRIPTION: HEIGHT:_____________________ HAIR COLOR:________________ CIRCLE ONE: Male Female WEIGHT:___________________ EYE COLOR:________________ CITIZEN: U.S.______ Other:_______ American LegalNet, Inc. www.FormsWorkFlow.com Current Address: Home: ______________________________________________________________________________ (Street) (City) (State) (Zip) Telephone # Home: (_____)-_______-_________ Work: (_____)-_______-_________ Past Residences: List of past residences from age 18 (include city, county, state and dates, month and year). City County State From (Yr.) To (Yr.) CRIMINAL HISTORY: A. Have you ever been arrested or detained? (Circle) Have you ever been convicted of a crime? (Circle) Have you ever been the subject of an indictment? Have you ever been subpoenaed for testimony or appearance? Have you ever been pardoned for any criminal offense? Yes Yes Yes No Yes Yes No No No No If "yes" to any of the above questions, provide the following information: -- Date of conviction -- 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? (Circle) Yes No If "yes", provide the following information: -- Date of offense -- Nature of offense -- City and State where offense occurred ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (use additional sheets if necessary) American LegalNet, Inc. www.FormsWorkFlow.com Civil Litigation Are you now or have you ever been involved in a civil legal action (Include bankruptcy and divorce proceedings). (Circle) Yes No -- Date of action -- City and State action was filed or litigated -- Nature of action -- Order or decision of the court ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ (use additional sheets if necessary) PREVIOUS GAMBLING LICENSES: A. Have you ever been licensed or denied a license by any government agency for the purpose of gambling? (circle) Yes No If "yes", provide the following information: -- Date licensed -- Agency issuing license -- Type of license held -- State where license was issued ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (use additional sheets if necessary) B. Have you been fingerprinted for any purpose within the last year?(circle) If "yes" provide the following information: -- Date Yes No --Agency receiving the fingerprint cards --Reason for fingerprinting ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 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 Employer's address From(MO/YR) To(MO/YR) American LegalNet, Inc. www.FormsWorkFlow.com (use additional sheets if necessary) OTHER LICENSING: Have you ever failed to file Federal or State income tax records? (circle) Have you ever had a sales or use tax permit revoked? Have you ever had any other license or permit revoked, denied or canceled? Have you ever failed to submit reports or pay taxes to any gambling agency? Please completely explain any "yes" answers below. YES YES YES YES NO NO NO NO ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (use additional sheets if necessary) 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: (Circle Answer) yes no 1.) Invested or loaned money, have an option to purchase, or have a contract for service to any other gambling facility or activity. yes no 2.) Have ownership interest in equipment being leased or otherwise provided to any gambling facilities. yes no 3.) Have an investment or own
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