RENEWAL APPLICATION FOR MANUFACTURER AND/OR DISTRIBUTOR GAMBLING DEVICESLICENSE APPLICATION TYPE: (Please check all licenses for which you are applying) *Used gambling devices are those manufactured five or more years ago.A. Manufacturer: 1.Manufacturer of 100 or fewer new devices 2.Manufacturer of more than 100 new devicesB. Distributor:(Fee $5,000 per year)(Fee $7,500 per year) 1.Distributor of 100 or fewer used devices 2.Distributor of more than 100 used devices(Fee $1,500 per year)(Fee $2,000 per year) 3.Distributor of 100 or fewer new devices 4.Distributor of more than 100 new devices(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. Name of Business Address City State Zip Code Country Phone Number Federal I.D. Number Other Business Name Address City State Zip Code Country Phone Number Federal I.D. Number Print Form BUSINESS CLASSIFICATION Corporation (mark appropriate box) Date of IncorporationCheck type of Corporation: Subchapter S Corporation Publicly Traded Corporation Closely Held Corporation State of Incorporation Partnership (attach copy of the partnership agreement) Sole Proprietorship During the past year has this company been licensed or applied for a license 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: During the past year 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: During the past year 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: During the past year 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: During the past year has the applicant ever commenced an administrative or judicial action against a governmental regulator of gambling? YES NO If yes, explain in detail: During the past year 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: During the past year has the applicant ever been delinquent in filing a tax report or remitting a tax imposed by any governmental agency? 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? 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 ANY INDIVIDUAL/PARTNERSHIP NOT ALREADY ON FILE WITH THE DIVISION: 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. Add Remove Add Remove Add Remove 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 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 NOIf no, please read and sign the following irrevocable consent. If yes, provide the following information: Name of Manager Mailing Address Add Remove Add Remove Add Remove Add Remove Street Address City State Zip Code Phone NumberIRREVOCABLE 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.SignatureDateATTACH 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 and this has changed in the past year, please provide:a.Articles of incorporationb.List of officers and board of directors or partnersc.List of stockholdersd.Partnership agreement3.Personal history statements4.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 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 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.SignatureDate(If a corporation, signer must be a corporate officer.) State of Minnesota Department of Public Safety Alcohol and Gambling Enforcement AUTHORITY TO RELEASE INFORMATIONI, Business, authorize and grant my consent to permit any law enforcement agency,and any other person, business or agency deemed necessary, to release any information requested by any identified law enforcement officer of the Minnesota Department of Public Safety, Alcohol and Gambling Enforcement Division.This information is for the express purpose of determining my eligibility for a gambling license issued under theauthority of Minnesota State Statutes. Business Name Signature (If a corporation, signer must be a corporate officer) Title DateSworn and subscribed before me this day of , Notary