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Fill and Sign the Axis Loan Application Form

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RESET State of Michigan Michigan Gaming Control Board Office of the Executive Director Gaming & Horse Racing Regulation Division 3062 W. Grand Blvd., L-700 Detroit, MI 48202 Phone: (313) 456-4100 Fax: 313-456-2864 www.michigan.gov/mgcb PRINT RACE MEETING LICENSE APPPLICATION ATTACHMENT A RACE MEETING LICENSE APPLICATION PERSONS ASSOCIATED WITH APPLICANT FORM ATTACHMENT A (Legal Name of Race Meet Applicant Business Entity) PERSONAL INFORMATION For each individual who is an applicant, a principal contact person for the applicant, a representative for the applicant, a corporate director, a corporate officer, a LLC member, a registered agent, partner, co-partner, and each corporate shareholder holding more than 15% of the issued corporate stock, the following information must be completed: 1. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street Address, City, State, Zip Code) Business Phone: Relationship to Applicant: 2. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street, City, State, Zip Code) Business Phone: MGCB-RAL-4059A (Rev. 07-14) Relationship to Applicant: 1 3. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street, City, State, Zip Code) Business Phone: Relationship to Applicant: 4. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street, City, State, Zip Code) Business Phone: Relationship to Applicant: 5. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street, City, State, Zip Code) Business Phone: MGCB-RAL-4059A (Rev. 07-14) Relationship to Applicant: 2 6. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street, City, State, Zip Code) Business Phone: Relationship to Applicant: 7. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street, City, State, Zip Code) Business Phone: Relationship to Applicant: 8. Full Legal Name: Prior Name/Alias: Social Security No: Date of Birth: Residence Address: (Street Address, City, State, Zip Code) Mailing Address: (Street Address or P.O. Box, City, State, Zip Code if different than Residence Address) Residence Telephone No: Occupation/Title: Employer: Employer Address: (Street, City, State, Zip Code) Business Phone: MGCB-RAL-4059A (Rev. 07-14) Relationship to Applicant: 3

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