Fillable Montana Personal/criminal History Statement

Print Form

PERSONAL/CRIMINAL HISTORY STATEMENT

Please type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply.

TYPE OF LICENCE YOU WISH TO OBTAIN:

(Check all that apply)



GAMBLING OPERATOR

LIQUOR OPERATOR

MANUFACTURER

DISTRIBUTOR

ROUTE OPERATOR

CARD DEALER



CARD ROOM CONTRACTOR

SPORTS TAB SELLER

NON-INSTITUTIONAL LENDER (NIL)

OTHER _________________________________

POSITION WITH BUSINESS:

(Check all that apply)



OWNER

SHAREHOLDER

PARTNER

MANAGER

OFFICER

DIRECTOR



OTHER ________________________________

MEMBER LLP

MEMBER LLC

Maiden

NAME: (Last, First, Middle)

SOCIAL SECURITY NUMBER:

City

County

HOME MAILING ADDRESS: (Street or PO Box)

Zip Code:

State or Country:

HOME PHONE:

WORK/CELL PHONE:

HOW LONG LIVING AT HOME ADDRESS ABOVE:

HEIGHT:

WEIGHT:

EYE COLOR:

HAIR COLOR:



RACE:

BIRTHDATE: (Month, Day and Year)

SEX:

DRIVER’S LICENSE NUMBER & STATE OF ISSUE:

MALE



FEMALE

DATE OF ENTRY: (Month, Day and Year)

If NO, give alien registration/entry visa/work permit number(s):

PORT OF ENTRY:

ARE YOU A U.S. CITIZEN?



YES

Maiden

SPOUSE’S NAME: (Last, First, Middle)

DATE OF MARRIAGE: (Month, Day and Year)

LICENSE HISTORY

List any business licenses that you have ever held, currently applied for, or have been denied/revoked/suspended in any state. If more space is needed,

attach additional sheets in the same format.

TYPE

LICENSE NUMBERS

BUSINESS NAME

STATE

LAST YEAR HELD

GAMBLING

LIQUOR

OTHER

CRIMINAL HISTORY STATEMENT

Circle Y (yes) or N (no) to answer

5. Been placed on probation?

Y / N

1. Been arrested?

Y / N

3. Been convicted? Y / N

whether you have EVER:

6. Forfeited bail or paid a ﬁ ne over $25 (Exclude trafﬁ c offenses except

2. Been charged with a crime? Y / N

4. Been Jailed?

Y / N

DUI and Reckless Driving)? Y / N

You must answer "YES" if any of the above have occurred, EVEN IF CHARGES WERE DISMISSED, DEFERRED OR CHANGED. Explain each charge fully

below and attach additional sheets as needed. False or incomplete information may result in denial, suspension or revocation of a license. If more space is

needed, attach additional sheets in the same format.

OFFENSE DATE

OFFENSE

CITY

COUNTY

STATE

DISPOSITION AND DATE

CONFIDENTIAL

LITIGATION HISTORY

Have you, as an individual, member of a partnership, or owner, director, or ofﬁ cer of a corporation, ever been a party to a lawsuit.  YES  NO

If yes, give details below. List all cases without exception, including bankruptcies. If more space is needed, attach additional sheets in the same format.

PLAINTIFF/DEFENDANT

COURT AND CASE NUMBER

CITY

COUNTY

STATE

DISPOSITION

Continue on to page 2 of this form.

FORM 10 REV 07/11