Gambling Proprietor's Form

Please provide the following contact information:

Name
Title
Organization
Business Type	Please specify if Native American to list correctly
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
FAX
E-mail
URL Address	Do not type in http://    it's already there!!!!!!!

Choose any or all of the following options for Casinos:

Hotel
Dining
RV park
Entertainment
Facilities or entertainment for children
Do you have a brochure to mail to potential visitors?

Tell us about your establishment or about any changes you wish to make.