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Minnesota Lawful Gambling
LG600 Manufacturer License Application

Business Information

Legal name of manufacturer _________________________________________________ Street address City

Annual fee $9,000

Fee__________ Check
DBA (doing business as), if applicable _________________________________________ State or province Postal code Country
____________________________________ _________________ __________________ ___________ __________ Mailing address, if different City State or province Postal code Country ____________________________________ _________________ __________________ ___________ __________ Phone number E-mail address Fax number ___________________________________ Minnesota tax identification number ___________________________________ Check one ____Sole proprietor ____________________________________ _____________________ Federal employer identification number __________________________________________________________ ____Corporation ____Limited liability company

____Partnership

Subsidiary, Affiliate, and Branch Information
(attach additional sheets if necessary)
List all subsidiaries, affiliates, and branches in which your company has any form of ownership or control, in whole or in part, without regard to whether the subsidiary, affiliate, or branch does business in Minnesota. Name of business Address City State or province Postal code Country Phone number ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

Owner Information

1. List all owners, partners, and persons or entities with a direct or indirect financial interest of 5% or more in the manufacturer. 2. For each person listed, attach a LG610 Manufacturer Personnel Information.

Name Title Name Title

__________________________________ ___________ __________________________________ ___________ __________________________________ ___________ __________________________________ ___________ __________________________________ ___________

Employee Information

1. 2. List all officers, directors, plant managers, and sales employees eligible to make sales in Minnesota. For each person listed, attach a LG610 Manufacturer Personnel Information. Title Name Title
__________________________________ ___________ __________________________________ ___________ __________________________________ ___________

Consultant Information

1. 2. List all consultants who provide advice for the sale or design of gambling equipment for sale in Minnesota. For each person listed, attach a LG610 Manufacturer Personnel Information. Name Name
Gambling Equipment Manufacturing Facilities
Address City State or province Postal code Country

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Phone number
________________________________________________________________________________________________________ ________________________________________________________________________________________________________
Storage Facilities in Minnesota
Address City, postal code Phone number
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
Product Manufactured for Sale in Minnesota
Check each type of product that will be sold in Minnesota: __ Pull-tabs __ Bingo hard cards __ Pull-tab dispensing device __ Bingo paper __ Tipboards __ Bingo number selection device __ Promotional tickets that mimic __ Electronic bingo device a pull-tab or tipboard __ Programmable electronic device __ Paddlewheel table __ Paddlewheel tickets __ Paddlewheel
Registered Agent and Address in Minnesota for nonresident manufacturers. Do not use PO box number
Name Address City Zip code Phone number
Other States in Which the Manufacturer is Licensed
List all states or jurisdictions in which the manufacturer is licensed.
__I declare that this application is correct and complete to the best of my knowledge and belief. __I will familiarize myself with the laws of the state of Minnesota and rules of the Board governing gambling and agree, if licensed, to abide by those laws and rules, including amendments to them. __I declare that I am qualified under the terms of Minnesota Rules 7864.0210 to be licensed as a manufacturer and will abide by the restrictions in Minnesota Rules 7864.0210, Subpart 3. __Changes in the information in this application will be submitted to the Board within 10 days of the change. _____________________________________________________________ Chief executive officer signature, in ink __________________________________________________ Print name ____________________________ Date _________________________________ Title

Attach and Mail

1. 2. 3. 4. LG600 Manufacturer License Application LG610 Manufacturer Personnel Information Organizational chart illustrating management structure Copy of logos used to identify the manufacturer on all gambling equipment to be sold in Minnesota 5. Check for $9,000, payable to "State of Minnesota"

Reset Form

Print Form
Mail to: Gambling Control Board 1711 W. County Road B, Suite 300 South Roseville, MN 55113 Questions? Contact the Gambling Control Board at 651-639-4079.
This publication will be made available in alternative format (i.e. large print, Braille) upon request.
Data privacy notice: The information requested on this form (and any attachments) will be used by the Gambling Control Board (Board) to determine your businesss qualifications to be involved in lawful gambling activities in Minnesota, and to assist the Board in conducting a background investigation of your business. You have the right to refuse to supply the information; however, if you refuse to supply this information, the Board may not be able to determine your businesss qualifications and, as a consequence, may refuse to issue your business a license. If you supply the information requested, the Board will be able to process your application. Your businesss name and address will be public information when received by the Board. All other information provided will be private data about your business until the Board issues your businesss license. When the Board issues your businesss license, all information provided will become public. If the Board does not issue your business a license, all information provided remains private, with the exception of your businesss name and address which will remain public. Private data about your business are available to: Board members, Board staff whose work requires access to the information; Minnesotas Department of Public Safety; Attorney General; Commissioners of Administration, Minnesota Management & Budget, and Revenue; Legislative Auditor, national and international gambling regulatory agencies; anyone pursuant to court order; other individuals and agencies specifically authorized by state or federal law to have access to the information; individuals and agencies for which law or legal order authorizes a new use or sharing of information after this notice was given; and anyone with your written consent.