Form 5 - Montana Alcoholic Beverage - Gambling Operator Combined License Application Page 4
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15Section II
Ownership Information
A. The applicant is a:
(See information checklist for documents required for each ownership type)
Individual(s) / Sole Proprietor(s)
Individuals and Partnerships may wish to apply
Partnership
as Joint Tenants with Rights of Survivorship
General
Limited
(JTROS) or Tenants in Common (TENCOM).
Limited Liability Company
Make certain each individual with right of
Limited Liability Partnership
survivorship or tenant in common is listed below.
Charitable or Non-Profit Organization qualified
JTROS or TEN COM
Under 26 U.S.C. 501(c)(3), (c)(4), (c)(8) or (c)(9)
Retirement home or nursing home (Gambling Only)
Corporation
C Corporation
Subchapter S
Publicly Held
In the spaces below, list all owners, partners, members, officers and/or directors. Each individual listed below must
submit 2 completed fingerprint cards, personal/criminal history statement and fees. Use additional sheet of paper if
necessary. For applicants that use a multiple entity structure, attach a diagram showing all entities and individuals.
Name (First, M.I., Last) _____________________________________________ Title ___________________________
Date of Birth _____________________Social Security No. ________________________ Number of Shares _______
Address ____________________________________________________________ Percentage of Ownership _______
Name (First, M.I., Last) ________________________________________________ Title ________________________
Date of Birth _____________________Social Security No. ________________________ Number of Shares _______
Address ____________________________________________________________ Percentage of Ownership _______
Name (First, M.I., Last) _____________________________________________ Title ___________________________
Date of Birth _____________________Social Security No. ________________________ Number of Shares _______
Address ____________________________________________________________ Percentage of Ownership _______
Section III
Section III
Management Information
A. Provide the following information for each management employee. If applying as an entity, include the manager
of the day-to-day operation for the business. Attach management agreement if applicable. Each individual listed
below must submit 2 completed fingerprint cards, personal/criminal history statement(s) and fee(s).
Gambling
Alcoholic Beverage
Both
N/A
Name _____________________________ Date of Birth _______________Social Security No. ___________________
Address ________________________________________________Phone ________________Salary ____________
Name _____________________________ Date of Birth _______________Social Security No. ___________________
Address ________________________________________________Phone ________________Salary ____________
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