White Earth Vendor Background Application for Vendor License
1.) Name of Business:______
2.) Business Address:______
______- ______
City State Zip
3.) Telephone Number: (_____) - ____ - ______4.) Federal I.D. #______
Type of services that will be provided______
______
HAS THE COMPANY EVER HAD ANY ACTION TAKEN AGAINST A GAMBLING
LICENSE BY ANY AGENCY in the last year?? (CIRCLE) Yes No If yes, explain and provide current
status.
______Fined ______
______Suspended ______
______Revoked ______
______Other Action ______
(use additional paper if necessary)
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 ______no -- Bankruptcy ______
______yes ______no -- Criminal ______
(use additional paper if necessary)
OTHER LICENSING
Have you ever had a sales and use tax permit revoked or canceled? YES NO
Have you ever had any other license or permit revoked, denied or canceled? YES NO
Have you ever failed to pay and gambling tax to any regulatory agency? YES NO
If “yes” to any of the above, provide complete details below.
______
______
______
______
______
______
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: (_____) - ______--______
PLEASE CHECK THE APPROPRIATE BOX AND PROVIDE THE
INFORMATION REQUESTED BELOW CONCERNING ANY
ADDITIONAL PERSONS WITHIN THE LAST YEAR.
_____ 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.
Name ______position______
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)
Name ______Date ______
Title ______
Telephone______
Please list any and all subsidiaries of this company or corporation include contact name and telephone number.
______
______
______
*Subsidiaries with a separate EIN number from the parent company, must obtain an individual vendor license.
Please notate and add any addendums to this document you deem beneficial in this application.
Notation by WEBI – 2010
AUTHORITY TO RELEASE INFORMATION
I, ______, authorize and grant my consent to permit
Business/ Contractor Name
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 White Earth Band of Chippewa Indians and the White Earth Backgrounds Investigations Department.
This information is for the express purpose of determining my eligibility for a Vendor license.
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 I meet the criteria for a license as established
by the Minnesota state law and department regulations.
______
(NAME OF BUSINESS)
Signature :______Title: ______
Date:______Seal
Sworn and subscribed before me this
______day of ______, 19__
Notary______
Thank you for your cooperation
Jason Clark
White Earth Tribal Gaming
Compliance Technician
Phone (218)935-5644
Fax (218)935-5087
Please enclose the annual fee along with the completed version of this application and remit to:
White Earth Backgrounds and Licensing
White EarthTribal Gaming Regulatory Authority Attn: Jason Clark
779 E Jefferson Ave
PO Box 395
Mahnomen, MN 56557
2
Form 10-3