Form CG-3 "Manufacturer License Application" - Kentucky

What Is Form CG-3?

This is a legal form that was released by the Kentucky Department of Charitable Gaming - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Kentucky Department of Charitable Gaming;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CG-3 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Charitable Gaming.

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Download Form CG-3 "Manufacturer License Application" - Kentucky

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Commonwealth of Kentucky
For Official Use Only:
Form CG-3
Public Protection Cabinet
 Fee paid
2018
DEPARTMENT OF CHARITABLE GAMING
MANUFACTURER LICENSE APPLICATION
KRS 238.530(3) PROVIDES THAT NO PERSON WHO IS LICENSED AS A
DISTRIBUTOR SHALL BE LICENSED AS A MANUFACTURER AND NO PERSON
LICENSED AS A MANUFACTURER SHALL BE LICENSED AS A DISTRIBUTOR.
A COMPLETE APPLICATION MUST BE RECEIVED AT LEAST SIXTY (60)
DAYS PRIOR TO THE INTENDED START OF LICENSE OR BEFORE THE
EXPIRATION OF YOUR CURRENT LICENSE.
GENERAL MANUFACTURER INFORMATION
1.
Name of applicant (manufacturer):


New
Renewal MAN-
Please list any other names under which you conduct business in the United States:
(Attach additional pages, if necessary)
2.
Is applicant organized as:
Corporation
Partnership
Limited Liability Co. (LLC)
Sole Proprietorship
Other
If "other", explain in detail:
3.
Mailing address:
City:
State/Zip Code:
County:
Telephone:
Fax Number:
Email address:
Website Address:
4.
Federal Employer Tax Number:
5.
Date of birth (if applicant is an individual):
Page 1 of 7
Commonwealth of Kentucky
For Official Use Only:
Form CG-3
Public Protection Cabinet
 Fee paid
2018
DEPARTMENT OF CHARITABLE GAMING
MANUFACTURER LICENSE APPLICATION
KRS 238.530(3) PROVIDES THAT NO PERSON WHO IS LICENSED AS A
DISTRIBUTOR SHALL BE LICENSED AS A MANUFACTURER AND NO PERSON
LICENSED AS A MANUFACTURER SHALL BE LICENSED AS A DISTRIBUTOR.
A COMPLETE APPLICATION MUST BE RECEIVED AT LEAST SIXTY (60)
DAYS PRIOR TO THE INTENDED START OF LICENSE OR BEFORE THE
EXPIRATION OF YOUR CURRENT LICENSE.
GENERAL MANUFACTURER INFORMATION
1.
Name of applicant (manufacturer):


New
Renewal MAN-
Please list any other names under which you conduct business in the United States:
(Attach additional pages, if necessary)
2.
Is applicant organized as:
Corporation
Partnership
Limited Liability Co. (LLC)
Sole Proprietorship
Other
If "other", explain in detail:
3.
Mailing address:
City:
State/Zip Code:
County:
Telephone:
Fax Number:
Email address:
Website Address:
4.
Federal Employer Tax Number:
5.
Date of birth (if applicant is an individual):
Page 1 of 7
OFFICER INFORMATION
6a. The following information is required for the chief executive officer and the chief financial officer of the
applicant. Note: These officers are subject to a state and FBI criminal history background check, and
fingerprinting will be required. Additional information relating to the procedures for the background
checks will be forwarded to the applicant.
Chief Executive Officer:
Chief Financial Officer:
Title:
Title:
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home Address:
Home Address:
City:
City:
State/Zip:
State/Zip:
Telephone: (
)
Telephone: (
)
Email Address:
Email Address:
6b.
The following information is required for officers of the applicant not listed in question #6a above:
Name:
Name:
Officer's title:
Officer's title:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home Address:
Home Address:
City:
City:
State/Zip:
State/Zip:
Telephone: (
)
Telephone: (
)
Email Address:
Email Address:
Name:
Name:
Officer's title:
Officer's title:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home Address:
Home Address:
City:
City:
State/Zip:
State/Zip:
Telephone: (
)
Telephone: (
)
Email Address:
Email Address:
Page 2 of 7
Name:
Name:
Officer's title:
Officer's title:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home Address:
Home Address:
City:
City:
State/Zip:
State/Zip:
Telephone: (
)
Telephone: (
)
Email Address:
Email Address:
Name:
Name:
Officer's title:
Officer's title:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home Address:
Home Address:
City:
City:
State/Zip:
State/Zip:
Telephone: (
)
Telephone: (
)
Email Address:
Email Address:
(Attach additional pages, if necessary)
FINANCIAL INTEREST
6c.
The following information is required for each individual who has a 10% or greater financial interest in the
applicant (manufacturer). Note: These individuals shall be subject to a state and FBI criminal history
background check, and fingerprinting will be required. Additional information relating to the procedures
for the background checks will be forwarded to the applicant.
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home Address:
Home Address:
City:
City:
State/Zip:
State/Zip:
Telephone: (
)
Telephone: (
)
Email Address:
Email Address:
(Attach additional pages, if necessary)
Page 3 of 7
MANAGEMENT
6d.
List all other persons with management responsibilities not listed above.
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home Address:
Home Address:
City:
City:
State/Zip:
State/Zip:
Telephone: (
)
Telephone: (
)
Email Address:
Email Address:
Please provide job title or position held and regular job duties:
(Attach additional pages, if necessary)
REGISTERED AGENT
7.
If applicant is not a resident of the Commonwealth of Kentucky, you must provide the name and
address of applicant’s registered agent in Kentucky. PO Box is not acceptable.
Name:
Address:
City/State/Zip:
Telephone: (
)
OTHER LICENSE(S)
8.
Is applicant currently licensed or permitted as a manufacturer of charitable gaming supplies and
equipment in any other states, territories or countries?
Yes or
No
If "Yes", please list the state, territory, or country:
State/territory/country:
State/territory/country:
Page 4 of 7
GENERAL INFORMATION
9.
Has the applicant had any disciplinary action taken by regulatory authorities in any other state,
territory, or country?
Yes or
No
If "yes", state when, by what regulatory authority, and on what grounds:
10.
Has the applicant ever been denied a license or permit in any state, territory, or country?
Yes or
No
If "yes", state when, by what regulatory authority and on what grounds:
11.
Has the applicant had any disciplinary action taken by any other regulatory authorities in the
Commonwealth of Kentucky?


Yes
or
No
If "yes", explain in detail the circumstances:
12a.
Has applicant or any individual named in question 6a, 6b, & 6c of this application been convicted of a
crime in federal court or the courts of any state, the District of Columbia, or any territory of the United
States?
Yes
or
No
If "yes", describe in detail:
12b.
Is the applicant or any individual named in question 6a,6 b, & 6c of this application above under indictment
in federal court or the courts of any state, the District of Columbia, or any territory of the United States?
Yes or
No
If “yes”, describe in detail:
Page 5 of 7
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