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Section IV

Financial Information

A. Financial or Ownership Interest: (Use additional paper if necessary.)

1. Does any person or entity listed in Section II (ownership information) have a financial or ownership interest in any

other gambling or alcoholic beverage enterprise?

Alcoholic Beverage:  Yes  No If yes, identify below.

Gambling:  Yes  No If yes, identify below.

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

2. Does any person listed in Section II, (ownership information) have family members with a financial or

ownership interest in any other gambling activity or alcoholic beverage enterprise? Include spouse, parents, children,

siblings.

Alcoholic Beverage:  Yes  No If yes, identify below.

Gambling:  Yes  No If yes, identify below.

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Indicate Alcoholic Beverage  Gambling 

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Indicate Alcoholic Beverage  Gambling 

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Indicate Alcoholic Beverage 

Gambling 



3. Do any persons or entities, other than those listed in Section II, (ownership information), have any financial or

ownership interest in, derive income from, or have liabilities associated with the business proposed for licensing?

The list must include, but is not limited to, any person or entity who has a right to share in the profits or has responsibility

for a financial obligation associated with the gambling or alcoholic beverage operation (including, assignees etc.) or to

whom any interest or share of profits has been pledged as security for the performance of a contract or sale related to

the business proposed for licensing. Do not include applicant’s route operator if the only interest the route operator

has is through a lease of vending/gambling machines.

Alcoholic Beverage:  Yes  No If yes, identify below.

Gambling:  Yes  No If yes, identify below.

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Individual(s) Name ___________________________ Enterprise Name__________________________________

Address ____________________________________________________________________________________

Form 5 - Montana Alcoholic Beverage - Gambling Operator Combined License Application Page 5