Applying for: Check one:           Gaming License     Non-Gaming License Check one: New Vendor License  Renew Vendor License
Company Name:			Today's Date:
Aliases:			Contact Name:
Street Address:			Telephone:
Suite:			FAX:
City:			E-mail:
State:	AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NF NS SK NT NU ON PE QC YT
Zip Code:			Tax ID #:
Type of business (check all that apply):	Sole Proprietorship Corporation Partnership Other		Names of all officers or partners (last, first and middle names):	1. 2. 3. 4. 5.
Type of business products or services			Other casinos with which you do business:
Treasure Island Resort & Casino contact:  Name: Phone #:			Volume of business:	Over $25,000     Under $25,000