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4. Has the applicant or any owner, partner, shareholder, LLC or LLP member, officer or director ever been issued a

gambling or alcoholic beverage license by any other agency, state, nation or jurisdiction?

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

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

Individual(s) Name ___________________________________________________Date _____________________

Type of License ______________________________ License Number __________________________________

State ____________City ________________County ___________________________ Country ______________

Individual(s) Name ___________________________________________________Date _____________________

Type of License ______________________________ License Number __________________________________

State ____________City ________________County ___________________________ Country ______________

Individual(s) Name ___________________________________________________Date _____________________

Type of License ______________________________ License Number __________________________________

State ____________City ________________County ___________________________ Country ______________

5. Does the applicant, or any member of the applicant’s immediate family, have any affiliation with, or financial interest

in, the operation of a state agency liquor store, an alcoholic beverage manufacturer, wholesaler/distributor or retailer

of alcoholic beverages in or out-of-state?

 Yes  No If Yes, list information below:

Business Name___________________________ Location __________________________________________

6. Has the applicant or any owner, partner, shareholder, LLC or LLP member, officer or director ever been denied an

alcoholic beverage or gambling license or had adverse action taken against an existing license by any agency, state,

nation or jurisdiction? If yes, describe in detail the nature of the violation and resulting adverse action.

 Yes

No __________________________________________________

Fined

 Yes

No___________________________________________________

Denied

 Yes

No___________________________________________________

Suspended

 Yes

No___________________________________________________

Revoked

Other Action or Action Pending  Yes

No ___________________________________________________

If Yes, list agency, location and date when license action was taken: