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									                                              Video Poker Renewal Checklist


D/B/A                                                               License #
Correct /                                                                                                      Missing /
Complete     The Following Info / Docs are Required for the Company:                                           Incomplete

             Correct renewal fee (check or money order only) Ck#_____________________________
             All forms typed, signed in blue or black ink
             Renewal Complete and Notarized (DPSSP 0049 R 1/2000)
             Request to Release Information (DPSSP 0037 R03/2008)
             Renewal Affidavit (DPSSP 0051(Company) R 3/2012)(For Company with no changes)
             Business, Trusts, Estates, Etc. Consent to Disclosure of Federal Tax Info
             Business, Trusts, Estates, Etc. Consent to Disclosure of State Tax Info
             Release of All Claims (DPSSP 0035 R03/2008)
             Afffidavit of Full Disclosure (DPSSP 0036 R 03/2008)
             Copy of Current Alcohol Tobacco Control Permit (Types 1 - 5)
             Corporation/Limited Liability Company in "Active" or "Good Standing with La. Secretary of State
             (to verify: Louisiana Secretary of State: www.sos.louisiana.gov)
             Tax Clearances: ______State ______Local ______Local Governing Authority Notification

Correct /    The Following Info / Docs are Required for all Individuals Required to Meet                       Missing /
Complete                                                                                                       Incomplete
             Suitability:
             Renewal Affidavit (DPSSP 0051(Individual) R 3/2012)
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______
             Request to Release Information (DPSSP 0037 R 03/2008) Notarized
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______
             Release of All Claims (DPSSP 0035 R 03/2008 ) Notarized
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______
             Individual Federal Consent to Disclosure of Tax Information - Sign and Date
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______
             Individual State Consent to Disclosure of Tax Information - Sign and Date
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______
             Affidavit of Full Disclosure ( DPSSP 0036 R 03/2008) Notarized
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______
             Personal History Questionnaire (DPSSP 0032 R 03/2008) (For individuals with changes)
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______
             Personal Financial Questionnaire (DPSSP 0033 R 03/2008) (For individuals with changes)
             ______, ______, ______, ______, ______, ______, ______, ______, ______, ______



Reviewer: ______________________________________                     Date: __________________



__________Entered                                     __________Copies of tax releases made

__________Logged in book as entered                   __________New license printed

revision 03/05/2012 alk

								
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