MISSOURI GAMING COMMISSION

Bingo Supplier or Manufacturer License Application

You must make accurate statements and include all material facts. Any misrepresentation, or the failure to provide requested information, may result in the denial of the application. Any statement that is not true or not disclosed which becomes known at any later date is cause for revocation of the Supplier’s License.

Note: The Commission notwithstanding the provisions of section 610.110, RSMo. has access to both closed and open records pursuant to section 313.004, RSMo. Please answer all the questions fully and thoroughly.

SUPPLIER’S LICENSE APPLICATION

A person who or an entity seeking to be licensed as a bingo supplier or manufacturer as defined in section 313.005, RSMo and 11 CSR 45-30.390 must submit this form.

INSTRUCTIONS

The applicant should respond to the questions contained herein to the best of its knowledge. Any misrepresentation or omission is grounds for application denial.

The applicant is under a continuing duty to disclose promptly any changes in the information provided in the application and requested materials submitted to the commission. The duty to make such additional disclosures shall continue throughout any period of licensure granted by the commission.

Sign forms in BLUE ink.

If the answer or material responsive to a question has been provided in response to another portion of the application, refer to the other portion.

A. FORMS

The original and one (1) copy of each of the following forms and items, appropriately organized and tabbed must be submitted in letter-size expansion envelopes by the applicant. All copies must be labeled with the applicant’s name. Mail the following forms and documents to:

Missouri Gaming Commission

Charitable Games Division

3417 Knipp Drive

PO Box 1847

Jefferson City, Missouri 65102

1.	Bingo Supplier’s or Manufacturer’s License Application.

2.	Personal Disclosure Form III. The applicant must submit this form if it is a sole proprietor. If the applicant is a business entity other than a sole proprietor, the applicant must submit this form for each of its key persons. The commission may require the applicant to submit this form for any individual who has an interest of any kind in the applicant;

3.	Schedule of exhibits;

4.	Applicant’s Request to Release Information;

5.	Release of All Claims;

6.	Affidavit of Full Disclosure;

7.	Verification;

8.	Applicable tax information/authorization forms; and

9.	Public Disclosure Section.

B. FEES

The initial, one-time, nonrefundable application fee shall be $5,000.

The annual renewal fee for the Supplier’s or Manufacturer’s license shall be $1,000.

Note that the applicant shall be responsible for the total cost of the investigation pursuant to section 313.057, RSMo. If the cost of the investigation exceeds the total amount of fees filed by the applicant, the commission may assess additional fees as it deems appropriate.

C. DEFINITIONS

Definitions contained in the statute and rules also apply to this application. In addition, for the purposes of this application, the following terms shall have the following meanings:

Applicant: Any individual or business entity that directly or indirectly has applied for a license.

Application: The total written materials, including the instructions, forms and other documents issued by the commission, comprising the applicant’s request for a license.

Attributed: Any direct or indirect interest in a business entity deemed to be held by an individual not through his/her actual holdings, but through holdings of his/her immediate family.

Best of Knowledge: The applicant’s knowledge after substantial inquiry.

Business Entity: A partnership, incorporated or unincorporated association or group, firm, corporation, limited liability company, partnership for shares, trust, sole proprietorship or other form of business.

Compensation: Anything of value, including salary, wages, commission, tips, gratuities, fees, bonuses, and distribution from (S) corporations, in any form including cash, securities, real property, and tangible and intangible personal property.

Contingent liability: Any obligation, indebtedness or claim, the amount of which cannot be definitely ascertained until the occurrence or nonoccurrence of some future event.

Control: The power to exercise authority over or direct the management and policies of an individual or business entity.

Debt instrument: Any bond, loan, mortgage, trust deed, note, debenture, subordination, guaranty, letter of credit, surety agreement, pledge, chattel mortgage or other form of indebtedness.

FEIN: Federal Employer Identification Number.

Felony: A criminal offense for which a sentence of imprisonment for one year or more may be imposed under the laws of any jurisdiction.

Financial statement: Any balance sheet, income statement, profit and loss statement, statement of cash flow, and sources and uses of funds statement.

Game: Any banking wagering, gaming or percentage game or activity, including those played with cards, chips, tokens, dice implements, devices or any electronic electrical, mechanical device or machine, which is played for money, property, or anything of value, including without limitation, baccarat, twenty-one, poker, craps, slot machines, video game of chance, roulette, Klondike table, punchboard, faro layout, keno layout, numbers ticket, bingo, push card, jar ticket, pull tab, horse racing, dog racing and jai alai.

Gaming Area: The room or rooms where bingo is conducted.

Immediate family: Spouse (other than a spouse who is legally separated from the individual under a decree of divorce or separate maintenance), parents, grandparents, children, grandchildren, whether by the whole or half blood, marriage, adoption or natural relationship.

Indirect: Any interest in a business entity that is deemed to be held by the holder, not through the holder's actual holdings in the business entity, but through the holder's holdings in other business entities.

Individual: Any natural person.

Key Person:

1.	An officer, director, trustee, proprietor, or managing agent, or general manager of an applicant or licensee or of a business entity key person of any applicant or licensee;

2.	A holder of any direct or indirect legal or beneficial publicly traded interest whose combined direct, indirect or attributed publicly traded interest is five percent (5%) or more in an applicant or licensee or in a business entity key person of an applicant or licensee;

3.	A holder of any direct or indirect legal or beneficial privately held interest whose combined direct, indirect or attributed privately held interest is one percent (1%) or more in an applicant or licensee or in a business entity key person of an applicant or licensee;

4.	A holder of any direct or indirect legal or beneficial interest in an applicant or licensee or in a business entity key person of an applicant or licensee if the interest was required to be issued under agreement with or authority of a government entity; and

5.	Anyone so designated by the commission or director.

Nominee: Any individual or business entity that holds as owner of record the legal title to tangible or an intangible personal or real property, including without limitation any stock, bond, debenture, note, investment contract or real estate on behalf of another individual or business entity, and as such is designated and authorized to act on his/her/its behalf with respect to such property.

Predecessor Company: A business entity which no longer exists in its original form but whose assets in substantial part have been acquired by another business entity or which had undergone certain internal changes, such as those of identity, form, or capital structure.

Public official: An individual who is elected to office pursuant to Missouri statute, or who is appointed to an office which is established under and the qualifications and duties of which are prescribed by Missouri statute to discharge a public duty for the state or any of its political subdivisions.

Publicly Held Company: A company that has filed a registration statement with the Securities and Exchange Commission.

Registered agent: Any individual or business entity against whom service of process may be made on behalf of any business entity or that is designated as such by any articles of incorporation or other corporate filings in any state.

Substantial creditor: The holder of any debt instrument of whatever character, against an individual or business entity, whether secured or unsecured, matured or unmatured, liquidated or unliquidated, absolute, fixed or contingent, the aggregate amount of which is fifty thousand dollars ($50,000) or more.

Application For a Bingo Supplier or Manufacturer License

Is Hereby Made To

The Missouri Gaming Commission

(Complete Name of Applicant)
(Address)
(Missouri Retailers Occupation Tax Number (If Applicable))
(Federal Employer Identification Number (FEIN))*
(Telephone Number)
(Contact Person)
(Contact E-mail Address)

Applicant requests a license to conduct the following activities in the State of Missouri:

Check all that apply:

Manufacture bingo equipment/supplies to be sold to Licensed Bingo Suppliers

Supply bingo equipment/supplies to Licensed Bingo Operators

* If applicant does not hold a FEIN number, state the proposed date for obtaining such number and the Internal Revenue Service District where federal tax filing will occur.

Transmittal Letter

Missouri Gaming Commission

Charitable Games Division

3417 Knipp Drive

PO Box 1847

Jefferson City, MO 65102

Dear Sir or Madam:

(Applicant’s Name) does herewith make application for a Bingo Supplier’s Manufacturer’s License.

In accordance with the Section 313.057, RSMo, the applicant submits herewith a check or money order in the amount of $5,000.00 as its nonrefundable application fee.

The applicant agrees to disclose and to require all of the persons associated with the applicant to disclose all information, documents and other material, which the commission may request at any time.

Further, the applicant agrees to furnish any additional information, documents and other material requested by the commission, and agrees that such additional material shall be made a part of this application.

The applicant acknowledges that neither the acceptance of this application not the issuance of a license hereunder shall imply that the Missouri Gaming Commission admits the truth of the statements herein made, or its approval thereof. Nor shall such acceptance or the issuance of a license constitute waiver or agreement by the commission with respect to any material contained in this application. The applicant further acknowledges that any license or any interest in any license issued by the commission is not transferable, and that subsequent legislation or regulation may diminish the value of any license issued by the commission to any extent possible.

The applicant has read and agrees to abide by the laws governing licensed gaming activities in Missouri and any rules promulgated by the commission, including any emergency rules and proposed rules.

Respectfully submitted,

(Applicant’s Name)
By:
(Officer)

A. APPLICANT INFORMATION

Identify applicant’s products:

If the space provided is insufficient, submit the identification as EXHIBIT 1(a).

Submit as EXHIBIT 1(b) two (2) copies of the following documents, as applicable:

(a)	Applicant’s complete product list by category and identify which products are sold in Missouri;

(b)	Applicant’s price list;

(c)	Applicant’s form lease agreement of tangible personal property;

(d)	Applicant’s form purchase agreement;

(e)	Applicant’s form service agreement;

(f)	Any contract and agreement between the applicant and holders of or applicants for any form of Missouri bingo license;

(g)	A certificate of good standing of the state of incorporation of applicant;

(h)	As applicable, a certificate of good standing issued by the Missouri Secretary of State indicating applicant is qualified to do business in the State of Missouri;

(i)	Certified copies of Articles of Incorporation and bylaws;

(j)	Partnership agreement; and

(k)	Audited financial statements of applicant and of any business entity of which the applicant is a substantial owner for the last three (3) fiscal years and for the period ending one (1) month prior to the date of application.

2.	(a)	Check the category below which describes the applicant’s business entity. An individual should apply as a sole proprietor if the other specific categories are not applicable. “Other” must be indicated for any business entity, which is not one of the specific categories listed. If “Other” is checked, an explanation of the business entity is required; if the space provided is insufficient, submit the explanation as EXHIBIT 2(a).

Corporation	Limited Partnership

General Partnership	Sole Proprietor

Holding Company	Trust

Limited Liability Company	Unincorporated Association

Other

(b)	Submit as EXHIBIT 2(b) a list identifying by name, address and telephone number all of the businesses which the applicant or any of its key persons owns directly or indirectly in whole or in part which are expected to do business with commission licensees in the year period commencing from the date of the application, and stating the total amount of business which each identified business is expected to conduct directly or indirectly with commission licensees during such period.

3.	Submit as EXHIBIT 3 a list identifying by name, address and telephone number any relative of the applicant or any of its key persons who holds a license issued by the commission or is a key person of a business entity which has applied for or holds a license issued by the commission.

4.	(a)	Submit as EXHIBIT 4(a) a detailed description of the applicant’s business, including the background and skills of the applicant and the applicant’s key persons, and identifying and describing any predecessor company of the applicant.

(b)	Submit as EXHIBIT 4(b) a list of all current and former addresses which the applicant has held or from which it has conducted business within ten (10) years from the date of filing this application, including the approximate time periods during which such addresses were held.

5.	If the applicant does business outside Missouri, submit as EXHIBIT 5 a statement listing all other jurisdictions where the applicant does business, describing the business activity conducted in those other jurisdictions, and listing all addresses from which the applicant currently does business.

6.	(a)	Submit as EXHIBIT 6(a) a schedule listing the name, business address and telephone number of the applicant’s Missouri –

(1)	Registered agent(s);

(2)	Legal services representative;

(3)	Accounting services representatives; and

(4) Banking and financial services representatives.

(b)	Submit as EXHIBIT 6(b) a schedule listing the name, business address and telephone number of the applicant’s other –

(1)	Registered agent(s);

(2)	Legal services representatives;

(3)	Accounting services representatives;

(4)	Banking and financial services representatives; and

(5)	Chief administrative officer.

7.	Submit as EXHIBIT 7 a detailed statement concerning the experience of the applicant and its key persons in providing its products.

8.	Does the applicant possess a gaming related license issued by any jurisdiction?

YES	NO

If the answer is “yes”, submit as EXHIBIT 8 two (2) copies of each license and a list of the following information:

(a) the type of license;

(b) the jurisdiction in which it was issued;

(c) any license number or identification number assigned to the license;

(d) the name, address, phone and facsimile numbers of the issuing agency; and

(e) the name of the appropriate contact person at the issuing agency.

9.	Have any of the securities of debt offerings of the applicant or any of the applicant’s substantial owners been suspended from trading or had action taken against them by any regulatory agency?

YES	NO

If the answer is “yes”, submit as EXHIBIT 9 a detailed statement describing each suspension, action, or both.

10.	Has the applicant or its key persons ever been or currently a party to a lawsuit (other than divorce proceedings)?

YES	NO

If the answer is “yes”, submit as EXHIBIT 10 a detailed list of all cases, including bankruptcies, stating for each lawsuit:

(a)	The name of the parties;

(b)	The case number;

(c)	The name of the court and its location;

(d) The type and nature of the case; and

(e)	The disposition of the case.

Submit copies of all complaints, petitions or similar pleadings, which initiated each lawsuit.

In addition, for all pending litigation, unsatisfied judgments, decrees, restraining orders, or injunctive orders, state:

(f)	In detail all pertinent facts, including the type and amount of relief sought; and

(g)	An assessment of the impact, if any, which the action may have on the applicant’s business.

11.	To the extent not already disclosed in your answer to question 10, state whether the applicant or its key persons have ever been involved in any formal or informal process of agreement to adjust, defer, suspend or otherwise work out the payment of any debt.

YES	NO

If the answer is “yes”, submit as EXHIBIT 11 a statement setting forth all details concerning each debt and the relating formal or informal process or agreement.

12.	State whether the applicant or its key persons or substantial creditors are delinquent in the payment of, or in dispute over the filings concerning the payment of any tax required under federal, state or municipal law.

YES	NO

If the answer is “yes”, submit as EXHIBIT 12 a detailed statement describing the delinquency or dispute, including the amount, type of tax, the taxing agencies and the time periods involved.

13.	State whether the applicant or its key persons or substantial creditors have ever had any municipal, state or federal tax returns audited or adjusted.

YES	NO

If your answer is “yes”, submit as EXHIBIT 13 a statement describing in detail the facts, circumstances and results of the audit or adjustment and copies of all Internal Revenue Service Forms 4549 and 4590 and any protest letters and other correspondence relating to any such audit or adjustment.

14.	If the applicant or any of its substantial owners is a corporation, submit the following as EXHIBIT 14:

(a)	The name, including all former trade, assumed or fictitious names, the address of the corporate headquarters, and the FEIN numbers for transporting gaming equipment held by each corporation;

(b)	The name of the state in which each corporation is incorporated, the date of incorporation, and, if a corporation is not incorporated in Missouri whether the corporation is authorized to conduct business in Missouri, the date the applicant commenced doing business in Missouri and a copy of the applicant’s certificate of authority to do business in Missouri;

(c)	A copy of the corporation’s Articles of Incorporation and bylaws;

(d)	For the present and former key persons of each corporation, their names, business names, positions, business and residential addresses and telephone numbers, and the amounts of and dates when compensation was received from the corporation during the three (3) years prior to the filing of this application;

(e)	For each corporation:

(1)	The classes of stock, attendant rights of each class and numbers of shares;

(2)	The number of shares authorized, issued, or outstanding;

(3)	The par value, market value and issue price of the shares;

(4)	The voting rights per class of stock (if the right of holders of any class of stock may be modified otherwise than by a vote of a majority or more of the outstanding shares so affected, voting as a class, so state and briefly explain);

(5)	The exchange, if any, on which any class of stock may be traded;

(6)	A list of the names, addresses and numbers of shares held for all holders of outstanding shares; and

(7)	A list of stock certificates which have been or will be pledged and the names, address and telephone number(s) of the pledgor and pledge of any stock certificated in a corporation, which is not a publicly held company;

(f)	If the beneficial owner of any stock in each corporation is an individual or business entity other than the owner of record or subscriber, the names and address of the owner of record or subscriber, the name and address of the beneficial owner, the conditions under which the owner of record or subscriber holds and votes or has subscribed for such stock; submit as EXHIBIT 14(f) a copy of any contract or other instrument relating to said conditions;

(g)	If within five (5) years from the date of filing this application there has been a change in the beneficial ownership of the equity securities of a corporation, including changes resulting from gift, purchase, sale, exercise of an option to purchase or sell, on the part of any individual or business entity who is or was a direct or indirect beneficial owner of ten percent (10%) or more of any class of an equity security of the corporation or who is or was a key person of the corporation, for each change of ownership state-

(1)	The date of transaction;

(2)	The nature of transaction;

(3)	The parties, including their position, to the transaction; and

(4)	The number, class and percentage of ownership of securities involved;

(h)	A description for each corporation of all stock warrants, options or common stock equivalents, which are authorized, issued and exercisable, including applicable lists of participant names, addresses and amounts of holdings.

(i)	If the applicant has any obligations or securities authorized or outstanding which bear voting rights either absolutely or upon any contingency, together with the nature of the obligations. In addition, the following shall be disclosed for each obligation:

(1)	The face or par value;

(2)	The number of units authorized;

(3) The number of units outstanding; and

(4)	Any conditions upon which the units may be voted.

(j)	The names in alphabetical order, and addresses of the directors. As to each director the following information shall be included:

(1)	The number of shares held of record as of the application date;

(a)	If the officer owns no shares the application shall so state; and

(b)	Ownership of shares shall include beneficial owners as that term is defined in section 313.600.4 RSMo.

(k)	The names, in alphabetical order, and addresses of the officers of the applicant. As to each officer the following information shall be included:

(1)	The number of shares held on record as of the application date;

(a)	If the officer owns no shares the application shall so state; and

(b)	Ownership of shares shall include beneficial owners as that term is defined in section 313.600.4 RSMo.

(l)	Each jurisdiction, including the United States, for which the corporation has met filing and disclosure requirements of state securities registration and filing laws, the Securities Act of 1933 or the Securities and Exchange Act of 1934. The applicant shall include the most recent registration statement and annual report filed with the Securities and Exchange Commission and each state in which the corporation has registered or filed the report:

(1)	If the applicant has not registered or filed any statements with the Commissioner of Securities of the secretary of State of Missouri the applicant must state the reason the filing has not been made including specific reference to the exception upon which the applicant relies for not filing with the Commissioner of Securities of the State of Missouri; and

(2)	If the applicant has filed with the Commission of Securities of the State of Missouri, copies of all filings beginning with the most recent up to and including the first statement filed or for the past five (5) years, whichever is shorter, shall be included in the application.

15.	If the applicant or any of its substantial owners is a business entity other than a corporation, submit as EXHIBIT 15:

(a)	A detailed description of the organization of each business entity;

(b)	For each business entity, as applicable, the applicant’s name, including all former trade, assumed and fictitious names, business and residential address and telephone number, Social Security number, and FEIN numbers for transporting gaming equipment, place and date of birth, occupation, place and date of organization, percentage of ownership and dates when participation occurred, and the amount of and dates when compensation was received for all present and former key persons of the business entity during the three (3) years prior to the filing of this application;

(c)	For each business entity, which is not organized under Missouri law, a statement identifying the law under which it is organized and stating whether it is authorized to conduct business in Missouri;

(d)	The names and addresses of each participant in each business entity which is a general partner, limited partner, unincorporated associated or other business entity other than a corporation; also submit as EXHIBIT 15(d) a statement answering question 15 for each such participant;

(e)	The name and address of each participant in each business entity which is a corporation; also submit as EXHIBIT 15(e) a statement answering question 14 for each such participant;

(f)	If the applicant is a partnership, a statement setting forth for each partner –

(1)	The amount of initial investment, whether in the form of cash, negotiable instruments, property or otherwise;

(2)	The amount and nature of any anticipated future investments;

(3)	The degree of control over the activities of the partnership; and

(4)	The method of distribution partnership profits;

(g)	If the applicant is an individual, then state –

(1)	The applicant’s legal name;

(2)	Whether the applicant is a United States citizen;

(3)	Any aliases or business names which have ever been or are being used by the applicant; and

(4)	Copies of the applicant’s state and federal tax returns for the past five (5) years;

(h)	Copies of any written agreement, constitution or other document creating or governing the applicant’s organization or powers of organization; and

(i)	The date the applicant commenced doing business in Missouri –

(1)	If the application is organized under laws other than the state of Missouri to do business in Missouri; and

(2)	If no authorization to do business in Missouri has been obtained, the applicant must state the reason the authorization has not been obtained.

16.	Submit as EXHIBIT 16 a description of all bonus, profit sharing, pension, retirement, deferred compensation and similar plans in existence or to be created by the applicant and any of its substantial owners, including:

(a)	The title or name of the plan;

(b)	The identity and address of the trustee of the plan or the person administering such plan;

(c)	The material features of the plan;

(d)	The methods of financing the plan;

(e)	The identity of each class of person who is or will participate in the plan;

(f)	The approximate number of persons in each such class; and

(g)	The amounts distributed under the plan to each class of persons during the last fiscal year it the plan was in effect during that time period.

17.	Submit as EXHIBIT 17, the names, in alphabetical order, and addresses of each partner, officer or other person having or sharing policy-making authority. As to each such person, the applicant must disclose –

(a) The nature and extent of any ownership interest;

(1)	Ownership interest shall include any beneficial owner which is covered by section 313.600.4, RSMo; and

(2)	Any voting interest, whether absolute or contingent and the terms upon which the interest may be voted.

18.	Submit as EXHIBIT 18, the names, in alphabetical order, and addresses of any individual or other entity who holds a record or beneficial ownership as defined in section 313.600.4, RSMo in the application. The following information shall be given concerning each individual:

(a)	The nature of the ownership interest;

(b)	Whether the ownership interest carries a vote and the terms upon which the interest may be voted; and

(c)	The percentage of ownership.

19.	State whether another individual or entity directly or indirectly controls to any extent or in any manner the applicant. If so, the applicant must disclose the identity of the controlling entity and a description of the nature and extent of the control and submit such as EXHIBIT 19. If the controlling entity is not an individual, the information required by this rule for the corporation or partnership or other organization controlling the applicant must be disclosed.

20.	Submit as EXHIBIT 20 any agreements or understanding which the applicant has entered into for the payment of fees, rents, salaries or other compensation(s) by the applicant or to the applicant. If the agreements or understandings are written, copies of the written documents must accompany the application. If the agreement or understanding is oral, the terms shall be reduced to writing and must accompany the application. Should the agreement or understanding be contingent in nature, the applicant shall disclose the nature of the contingency.

21.	Submit as EXHIBIT 21 a disclosure of whether the applicant or any key person currently holds or has ever held a license or permit issued by a governmental authority to own or supply gaming equipment or operate a gaming facility or conduct any aspect of gambling. If the applicant has held or holds a license or permit, the applicant must disclose:

(a)	The identity of the license or permit holder;

(b)	The jurisdiction issuing the license or permit;

(c)	The nature of the license or permit; and

(d)	The dates of issuance and termination, if any.

22.	Submit as EXHIBIT 22 a statement of whether any person currently serving, or any person who has within the past two (2) years served, as a member of the commission, an employee of the commission, a member of the General Assembly, or as an elected official of the state, or of any city or county in the state in which licensing of excursion gambling boats has been approved, has any ownership interest in the applicant.

23.	Submit as EXHIBIT 23 a statement listing the names, titles, addresses and telephone numbers of all public officials or officers of employees of any unit of government, and relatives of said public officials officers or employees, who, directly or indirectly, own any financial interest in, have any beneficial interest in , are the creditors of or hold any debt instrument issued by, or hold or have any interest in any contractual or service relationship with, the applicant or any of its key persons.

24.	State whether the applicant or any of its substantial owners has made, directly or indirectly, any political contribution, or any loans, donation or other payments to any individuals or business entities for the purpose of making political contributions, within five (5) years from the date of filing this application:

YES	NO

If your answer is “yes”, submit as EXHIBIT 24 a statement setting forth for each such contribution, loan, donation, or other payment:

(a)	The amount;

(b)	The method of payment;

(c)	The name of the candidate or office holder;

(d)	The office sought or held; and

(e)	The recipient.

25.	State whether the applicant or any of its substantial owners, has been arrested, detained, charged, indicted, convicted, pleaded guilt or nolo contendere, or forfeited bail concerning any criminal offense under the laws of any jurisdiction, either felony or misdemeanor (except for traffic violations the maximum possible punishment for which was a fine not in excess of fifty dollars ($50):

YES	NO

If the answer is “yes”, submit as EXHIBIT 25 a statement setting forth for each case:

(a)	The date;

(b)	The names, addresses and telephone numbers of the individuals and business entities involved;

(c)	The name and location of the court, arresting agency and prosecuting agency;

(d)	The case number;

(e)	The offense;

(f)	The disposition; and

(g)	The location and length of incarceration.

26.	State whether the applicant or any of its substantial owners has had any license or certificate issued by a licensing authority denied, restricted, suspended, revoked or not renewed:

YES	NO

If the answer is “yes”, submit as EXHIBIT 26 a statement describing in detail the facts and circumstances concerning such denial, restriction, suspension, revocation or non-renewal, including the licensing authority, the date each such action was taken, and the reason for each such action.

27.	Submit as EXHIBIT 27 a statement containing:

(a)	A list of all debt instruments of the applicant or any of its substantial owners;

(b)	A list of the names, addresses and telephone numbers of all holders of each debt instrument; and

(c)	A list of the amount of outstanding debt relating to each debt instrument.

28.	Submit as EXHIBIT 28(a), 28(b) and 28(c), as applicable, statements setting forth the following:

(a)	A detailed description of the relationship, as applicable, between applicant and any holder of any form of Missouri bingo license;

(b)	A detailed description of the applicant’s ownership, as applicable, of any holder of or applicant for any form of Missouri bingo license;

(c)	A detailed description of any transaction in the last five years, or contemplated in the future, as applicable, between the applicant and any holder of or applicant for any form of Missouri bingo license; submit any document relating to each transaction.

29.	Submit as EXHIBIT 29 a statement listing the names, addresses and telephone numbers of each individual or business entity having an interest of any kind of the applicant not disclosed elsewhere, and describing in detail the nature, facts and circumstances concerning each such individual, business entity and interest.

B. BUSINESS INFORMATION

30.	Submit as EXHIBIT 30(a) through EXHIBIT 30(l) as applicable, detailed statements stating and describing:

(a)	Applicant’s products, any other principal goods produced or services rendered, including any significant changes in the kinds of products, other goods or services, and the principal markets for and methods of distribution of such products, other goods or services, including any significant changes in the markets and methods of distribution during the past three (3) fiscal years;

(b)	The competitive conditions concerning the industry or industries relating to, and the competitive position in such industry or industries of, the applicant’s products, any other principal goods

(c)	If a material part of the applicant’s business is dependent upon a single customer or a few customers, for each such customer state;

(1)	Its name, business address, and telephone number; and

(2)	Its relationship with and its importance to the applicant’s business.

(d)	If backlog is a factor affecting the applicant’s business operations, state;

(1)	The dollar amount of backlog orders believed to be firm as of a date during the current fiscal year and as of comparable dates during the preceding two (2) fiscal years;

(2)	The portion of current backlog orders not reasonably expected to be filled within the current fiscal year; and

(3)	The seasonal or other material aspects of the backlog.

(e)	The sources and availability of raw materials essential to the applicant’s business;

(f)	The duration, importance, effect and holders of all patents, trademarks, copyrights, licenses, franchises and concessions which are material to the applicant’s business;

(g)	The circumstances surrounding and results of any bankruptcy, receivership or similar proceedings affecting the applicant’s business;

(h)	The circumstances surrounding and the results of any material reorganization, merger, consolidation, readjustment or succession of the applicant’s business;

(i)	The acquisition or disposition of any material amount of assets other than in the ordinary course of the applicant’s business during the past three (3) years;

(j)	Any material changes in the mode of conducting applicant’s business during the past three (3) years;

(k)	A summary of warranties in effect on the applicant’s products, including claims relating to such warranties; and

(l)	A summary of all litigation relating to the applicant’s products.

31.	Submit as EXHIBIT 31 a list identifying by name, address and telephone number all distributors, sales representatives or other individuals or business entities which formally or informally distribute, market or represent any good produced or service rendered by the applicant.

32.	Submit as EXHIBIT 32 a statement confirming that the applicant is fully registered and licensed in accordance with all laws necessary to enable the applicant to provide its products. Submit two (2) certified copies of all certificates, registrations and licenses.

33.	Submit as EXHIBIT 33 a detailed statement describing the methodology to be used to insure that the entire workforce to be employed by the applicant in connection with the providing of its products will be in accord with the requirements of all pertinent federal and Missouri equal employment opportunity laws.

34.	Submit as EXHIBIT 34 a list of the names, addresses and telephone numbers of each individual for whom a Personal Disclosure Form III will be submitted.

Bingo Supplier / Manufacturer License Application

Schedule of Exhibits

This schedule relates to the application of:

(Complete Name of Applicant)

to obtain a Missouri Gaming Commission issued Bingo Supplier or Manufacturer License.

If an exhibit is not applicable, indicate “N.A.”.

Exhibit Number	Person who made or directed preparation of exhibit (state which)	Official Title
1(a)
1(b)
2(a)
2(b)
3
4(a)
4(b)
5
6(a)
6(b)
7
8
9
10
11
12
13
14
14(f)
15
15(d)
15(e)
16
17
18
19
20
21
22
23
24
26
27
28(a)
28(b)
28(c)
29
30(a)
30(b)
30(c)
30(d)
30(e)
30(f)
30(g)
30(h)
30(i)
30(j)
30(k)
30(l)
31
32
33
34

Applicant’s Authorization and Request to Release Information

To:
(Leave Blank)
From:
(Applicant’s Name)

1.	The applicant hereby authorizes and requests all persons to whom this request is presented having information relating to or concerning the applicant to furnish such information to a duly appointed officer of the Missouri State Highway Patrol, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or other legal privilege.

2.	The applicant hereby authorizes and requests all persons to whom or entities to which this request is presented having documents relating to or concerning the applicant to permit a duly appointed officer of the Missouri State Highway Patrol to review and copy any such constitutional, statutory or other legal privilege.

3.	If the person to whom or entity to which this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or an officer of same, the applicant hereby authorizes and requests that a duly appointed officer of the Missouri State Highway Patrol be permitted to review and obtain copies of any documents, records or correspondence pertaining to the applicant, including, but not limited to, past loan information, notes co-signed by applicant, checking account records, savings deposit records, safe deposit box records, passbook records and general ledger folio sheets.

4.	The applicant hereby makes, constitutes and appoints any duly appointed officer of the Missouri State Highway Patrol the applicant’s true and lawful attorney-in-fact for the applicant in the applicant’s name, place, stead, and on the applicant’s behalf and for the applicant’s use and benefit:

(A) To request, review, copy, sign for, or otherwise act for investigative purposes with respect to documents and information in the possession of the person or entity to whom this request is presented as the applicant might;

(B)	To name the person or entity to whom this request is presented and insert that person’s or entity’s name in the appropriated location on this request; and

(C)	To place the name of the Missouri State Highway Patrol’s officer presenting this request in the appropriate location on this request.

5.	The applicant grants to said attorney-in-fact full power and authority to do, take, and perform all and every act and thing whatsoever requisite, proper, or necessary to be done, in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the applicant might or could do, with full power of substitution of revocation, hereby ratifying and confirming all that the attorney-in-fact, or his/her substitute(s), shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.

6.	This power of attorney ends twenty-four (24) months from the date of execution or at the termination of all licenses issued to the applicant by the Missouri Gaming Commission, whichever occurs later.

7.	The applicant has filed the “Application” with the Missouri Gaming Commission. The applicant understands that he, she, it is seeking the granting of a privilege and acknowledges that the burden of proving the applicant’s qualifications for a favorable determination is at all times on the applicant. The applicant accepts any risk of adverse public notice, embarrassment, criticism or other action of financial loss, which may result from action with respect to this application.

8.	The applicant does, for itself, its heirs, executors, administrators, successors and assign, hereby release, remise, and forever discharge the person or entity to whom this request is presented, and his/her/ its agents and employees from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which the applicant ever had, now has, may have, or claim to have against the person or entity to whom this request is presented or his/her/its agents or employees arising out of or by reason of complying with this request.

9.	The applicant agrees to indemnify and hold harmless the person or entity to whom this request is presented and his/her/its agents and employees from and against all claims, damages, losses, and expenses, including reasonable attorney’s fees arising out of or by reason of complying with this request.

10.	A reproduction of this request by photocopy shall be for all intents and purposes as valid as the original.

IN WITNESS WHEREOF, I have executed this request at

(City)	(State)

on the ______ day of ___________________ 20______.

Applicant:
By:

Subscribed and sworn to before me this _________ day of _____________________, 20____

___________________________________

(Notary Public)

My commission expires: _______________

(Notarial Seal)

Notary Public in and for the County of _____________________________

State of _____________________________________________________

Release of All Claims

The undersigned has filed with the Missouri Gaming Commission (commission) certain forms and documents in connection with a written request for licensing by the commission (“Application”). In consideration of the assurance by the commission that no vote on the application will be taken except after a deliberate, intensive and thorough investigation of the undersigned, including, but not limited to, background, successors and assigns, hereby release, remise, and forever discharge the State of Missouri, the commission, its members, agents, and employees, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which the undersigned ever had, now has, may have, or claim to have against any or all of said entities or individuals arising out of or by reason of the processing or investigation of or other action relating to the application.

I, the duly authorized (Office) of the undersigned, have read this affidavit and understand its terms. On behalf of and in accordance with the instructions of the undersigned, I execute it with full knowledge that the undersigned will be bound hereby.

IN WITNESS WHEREOF, I have executed this release at

(City)	(State)

on the_________ day of ______________, 20___

By:	(Applicant)
Its:

Subscribed and sworn to before me this _________ day of _____________________, 20____

___________________________________

(Notary Public)

(Notarial Seal)

My commission expires: _______________

Notary Public in and for the County of _____________________________

State of _____________________________________________________
Affidavit of Full Disclosure

State of	SS
County of

I, (Officer Name), being the duly authorized (Office) of (Name of Applicant), being first duly sworn upon oath or affirmation, depose and state:

That, except as reported in the applicant’s Application (“Application”), the applicant has no agreements or understandings with any person or entity and no present intent to hold as agent, nominee or otherwise any interest in the Application;

That, except as reported in the Application, the applicant has no agreements or understandings with any person or entity and no present intent to pay any sums of money or give anything of value as, including, but without limitation, a finder’s fee or commission to any person or entity related to the acquisition of any interest in the Application;

That, except as reported in the Application, the applicant has no agreements or understandings and no present intent to pay any sums of money or give anything of value as, including, but without limitation, a finder’s fee or commission to any person or entity related to the sale of any interest in the Application;

That, any funds used or to be used, and any liabilities incurred or to be incurred by the applicant in the acquisition of any interest in the Application were not provided to the applicant or made available to the applicant through the efforts of any person or entity not reported in the Application;

That, except as reported in the Application, no person or entity has provided collateral for or guaranteed payment of any loans made to the applicant which relate to the Application.

I, the duly authorized (Office) of the undersigned, have read this Affidavit of Full Disclosure and understand its terms. On behalf of and in accordance with the instructions of the undersigned, I execute it with full knowledge that the undersigned will be bound hereby.

By:	(Applicant)
Its:

Subscribed and sworn to before me this _________ day of _____________________, 20____

___________________________________

(Notary Public)

(Notarial Seal)

My commission expires: _______________

Verification

State of	SS
County of

I, (Officer Name), being the duly authorized (Office) of (Applicant Name), being first duly sworn upon oath or affirmation, depose and state:

1.	On behalf of the applicant, I am the individual who is submitting this application;

2.	I personally supplied the information contained in this application;

3.	I swear (or affirm) that the information contained in this application is true, complete and accurate to the best of my knowledge and belief;

4.	I swear that I have read and agree to abide by the laws governing licensed gaming activities in Missouri and any rules promulgated by the commission, including any emergency rules and proposed rules.

___________________________________

(Officer’s Signature)

Subscribed and sworn to before me this _________ day of _____________________, 20____

___________________________________

(Notary Public)

(Notarial Seal)

My commission expires: _______________

Notary Public in and for the County of _____________________________

State of _____________________________________________________

IMPORTANT

Form 4506-T, Request for Transcript of Tax Return

Form 4506-T can be found at the following site: http://www.irs.gov/pub/irs-pdf/f4506t.pdf

Do NOT mail or fax Form 4506-T to the Internal Revenue Service

When completing the form:

Enter the following information for question 5:

Missouri Gaming Commission

P.O. Box 1847

Jefferson City, MO 65102

(573) 526-4080

Place a check in box 6b

Complete and sign the form and submit it to the Missouri Gaming Commission along with your completed application.

Form 4506-T is completed and included with my application.

IMPORTANT

Form 943, Request for Tax Clearance

Form 943 can be found at the following site:

Do NOT mail or fax Form 943 to the Missouri Department of Revenue

When completing the form:

Under “Reason(s) for Request”, for question number 3:

Place a check in box “Other”

List “Missouri Bingo Supplier/Manufacturer License Renewal”

Under “Authorization”, enter the following information:

Name of Person Authorized to Receive This Information:	Dwell Isringhausen, Missouri Gaming Commission
Title:	Sergeant
Phone Number:	(573) 526-4080
Address:	P.O. Box 1847
City:	Jefferson City
State:	MO
Zip Code:	65102
Email Address of Authorized Person:	Dwell.Isringhausen @mgc.dps.mo.gov

Complete and sign the form and submit it to the Missouri Gaming Commission along with your completed application.

Form 943 is completed and included with my application.

Public Disclosure Section

Instructions: All applicants for licensure and all licensees are required to fully and completely supply all information concerning the applicant or licensee, his/her/its products, service or gambling enterprises and his/her/its business holdings requested by this form even though much of the information requested may have been previously disclosed in the application. Where the answer may be derived or ascertained from the business records of the applicant or licensee, the applicant or licensee may attach such records as exhibits and reference the exhibits in the corresponding answer. This form will be used by the Missouri Gaming Commission to comply with the provisions of the gaming law requiring public disclosure of this information to any person upon request. Each applicant and licensee has a continuing obligation to update and supplement the information contained in this form. Portions of the form may not apply to each applicant and licensee; however, each applicant and licensee is instructed to complete all sections of the form that apply.

Submit the original and one (1) copy of your responses together with the public disclosure verification as a separate attachment to the Application for the following requests:

1.	State the name, business address and business telephone number of the applicant or licensee.

2.	State whether the applicant of licensee is a sole proprietor, unincorporated association, limited partnership, general partnership, corporation, limited liability company, holding company, holding company, trust or other business entity. If the applicant or licensee is not an individual, provide information on the state of incorporation or registration, a list of the corporate officers, the identity of all shareholders or participants and the percent of their interest. If an applicant or licensee has a pending registration statement filed with the Securities Exchange Commission, the names of those persons or entities holding interest must be provided.

3.	State whether the applicant or licensee or applicant’s or licensee’s spouse or children has an equity interest in any business. If so, identify and describe any business, including, if applicable, the state of incorporation or registration. If applicant or licensee is a corporation, partnership or other business entity, state and identify any other corporation, partnership or business entity in which it has an equity interest, including, if applicable, the state of incorporation or registration. This information need not be provided by a corporation, partnership or other business entity that has a pending registration statement filed with the Federal Securities and Exchange Commission.

4.	State whether the applicant or licensee has been indicted, convicted, pleaded guilty or nolo contendere, or forfeited bail concerning any criminal offense under the laws of any jurisdiction, either felony or misdemeanor, except for traffic violations. If so, include the date, the name and location of the court, arresting agency and prosecuting agency, the case number, the offense, the disposition and the location and length of incarceration.

5.	State whether the applicant or licensee has had any license or certificate issued by a licensing authority in this state or any jurisdiction denied, restricted, suspended, revoked or not renewed and a statement describing the facts and circumstances concerning the denial, restriction, suspension, revocation or non-renewal, including the licensing authority, the date each action was taken and the reason for each such action.

6.	State whether the applicant or licensee has ever filed or had filed against it a proceeding in a bankruptcy or has ever been involved in any formal process to adjust, defer, suspend or otherwise work out the payment of any debt including the date of filing, the name and location of the court, the case and number of the disposition.

7.	State whether the applicant or licensee has filed, or been served with a complaint or other notice filed with any public body, regarding the delinquency in the payment of, or a dispute over the filings concerning the payment of, any tax required under federal, state or local law, including the amount, type of tax, the taxing agency and the time periods involved.

8.	State the names and titles of all public officers or officers of any unit of government, and relatives of those public officials or officers who, directly or indirectly, own any financial interest in, have any beneficial interest in, are the creditors of or hold any debt instrument issued by, or hold or have any interest in any contractual or service relationship with the applicant or licensee.

9.	State whether the applicant of licensee has made, directly or indirectly, any political contribution, or any loans, donations or other payments of one hundred dollars ($100) or more, to any candidate or office holder, within five (5) years from the date of filing this form, update or supplement. Specify to whom the payment was made, the amount of the payment and the method of payments.

10.	State the name, business address, and business telephone number of the legal counsel, if any, representing the applicant or licensee in matters before the commission.

11.	If an applicant for or holder of a supplier’s license, provide a description of the product(s) or service(s) to be supplied within the state.

Public Disclosure Verification

State of	SS
County of

I, , being first duly sworn upon oath or affirmation, depose and state:

1.	I am the applicant or licensee submitting this Public Disclosure Section.

2.	I personally supplied the information contained in this form.

3.	I swear (or affirm) that the information contained in this form is true, complete and accurate to the best of my knowledge and belief.

4.	I understand and agree that the Public Disclosure Form will be provided to any member of the public who requests this information from the Missouri Gaming Commission. I further understand my continuing obligations to update and supplement this form if any of the information provided changes.

5.	I swear that I have read and agree to abide by the laws governing licensed gaming activities in Missouri and any rules promulgated by the commission, including any emergency rules and proposed rules.

______________________________________

(Individual’s Signature)

Subscribed and sworn to before me this _________ day of _____________________, 20____

______________________________________

(Notary Public)

(Notarial Seal)

My commission expires: __________________

Notary Public in and for the County of _____________________________

State of _____________________________________________________