Form Da101 - Lawful Gambling Distributor Permit Application Page 2
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2Form DA101 page 2
List the name and address of each manufacturer from whom you purchase or intend to purchase gambling supplies.
Name
Address
City
State
ZIP Code
Name
Address
City
State
ZIP Code
Name
Address
City
State
ZIP Code
Name
Address
City
State
ZIP Code
Name
Address
City
State
ZIP Code
Name
Address
City
State
ZIP Code
Customer base (check all that apply):
Licensed Gambling Organizations
Exempt Organizations
Businesses and/or Individuals
Native Americans
Out-of-State Businesses
Promotional Pull-Tabs
Other
Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we must advise you of the following:
• This information may be used to deny the issuance or renewal of your license if you owe the Minnesota Department of Revenue delin-
quent taxes, penalties or interest.
• Under the Federal Exchange of Information Act, the Department of Revenue is allowed to supply this information to the Internal Rev-
enue Service.
• Failing to supply this information may jeopardize or delay the issuance of your permit.
I acknowledge that by becoming licensed as a lawful gambling distributor, I will have record keeping/reporting requirements and respon-
sibilities. I agree to comply with the applicable tax statutes as a condition of my permit, and declare that the information given in this
application is true, correct and complete to the best of my knowledge and belief.
Authorized Signature
Title
Date
Daytime Phone
Mail to: Minnesota Revenue, Mail Station 3350, St. Paul, MN 55146-3350.
Phone: 651-297-1772. Email: lawfulgambling.taxes@state.mn.us
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Parent category: Financial