Sd Eform 1338 - Application For License To Distribute Bingo And Lottery Equipment And Supplies - South Dakota Department Of Revenue Page 3

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Application License To Distribute Bingo And Lottery Equipment And Supplies
Distributor Personnel Information Form
1.
Name and Address of Distributor
Phone
2.
Name of Individual (and previously used names)
Work Phone
3.
Home Street Address
City
State
Zip
Home Phone
4.
Driver’s License No.
State of Issue
Date of Birth
5.
State of Birth
Name of Spouse
Date of Birth
6.
Position with Organization
Owner
Director
Partner
Manager/Supervisor
Corp. Officer
7.
Other current occupations and places of employment (list employer, city, state, type of business,
position held). If self-employed, list details.
8.
Places of residence for the past 10 years (street address, city, state, zip)
9.
Criminal History Statement (except minor traffic violations, attach additional sheets if needed)
Date
Charge
City & State
Disposition

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