Free PD2 Indiana Gaming License Application - Indiana

INDIANA GAMING COMMISSION East Tower, Suite 1600 101 W. Washington Street Indianapolis, Indiana 46204-3408

PERSONAL DISCLOSURE FORM 2

This form must be submitted by Applicants seeking an Occupational License Level 2. If a prospective Applicant has any questions about whether he/she should submit this form, consult 68 Indiana Administrative Code 2-3 (http://www.in.gov/legislative/iac/title68.html) or contact Indiana Gaming Commission staff.

This form is authorized as outlined by IC 4-33 and IC 4-35 and fulfills the application requirements therein. Disclosure of this information is REQUIRED. Failure to provide information could result in rejection of or delay in processing this application.
State Form 46781 (R/3-08)

Approved by State Board of Accounts, 2008

Personal Disclosure Form 2

INSTRUCTIONS
· · Submit the original form to the Commission and keep a copy for your records. Applicant is advised that this Application is subject to the Access to Public Records Act (APRA), IC 5-14-3, and, after the Application has been submitted, it may be viewed and copied by any member of the public, including news agencies and competitors. If Applicant claims a statutory exception to the APRA and wishes to declare an answer or section of the Application as confidential, Applicant must write the word "Confidential" on each applicable page or attachment and must specify which statutory exception of APRA makes the subject information confidential. The Commission reserves the right to make determinations of confidentiality. If the Applicant does not identify the statutory exception, the Commission may not consider the information confidential. If the Commission does not agree that the information designated is confidential under one of the disclosure exceptions to APRA, it may seek the opinion of the Public Access Counselor before releasing the designated information. Pursuant to 68 IAC 2-3-4, your social security number is required to process your Application. If your social security number is not disclosed, your Application may be denied. Read each question completely before answering. When an answer or exhibit responsive to a question has already been submitted in response to another question on this form, you may refer to your prior answer. When a question does not apply to you, indicate by stating "Does not apply." If you have no answer to a certain question, indicate by stating "None." Type or write legibly. If your Application is not legible, it will not be accepted. Initial all pages in the upper right-hand corner. Attach a recent photograph (within the last 6 months) of yourself in the space provided on page 8. FOR UNITED STATES CITIZENS BORN IN THE UNITED STATES OR UNITED STATES TERRITORIES: Attach a copy of your official United States birth certificate containing your date of birth, place of birth, and parents' names in the space provided on page 8. The birth certificate must be issued by a county department or board of health from your state of birth, a state department or board of health from your state of birth, or a United States territory. If a birth certificate is not available, a copy of a letter from you to the appropriate government agency requesting a birth certificate will be acceptable for processing a temporary license. The letter must show both the name and address of the agency from which the birth certificate is requested. A permanent occupational license will not be issued until the applicant provides a copy of the birth certificate or evidence indicating that the records have been destroyed or are no longer available.
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Personal Disclosure Form 2

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FOR FOREIGN-BORN UNITED STATES CITIZENS: Any of the following documents will be acceptable. If one of the following documents is not available, a copy of a letter from you to the appropriate government agency requesting the appropriate naturalization document will be acceptable. The letter must show both the name and address of the agency from which the document is requested. a) Certificate of Naturalization/Citizenship; b) Certification of Report of Birth (DS-1350); c) Consular Report of Birth (FS-240);

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FOR NON-CITIZENS: Any of the following documents will be acceptable: a) United States Military/Merchant Marines identification card with photo; b) United States Veterans Universal Access and Identification Card with photo; c) Valid foreign passport with a photo and a visa that includes a valid Form I-94 indicating the authorized duration of stay in the United States; d) Valid foreign passport with a current visa that states "Upon Endorsement Serves as Temporary I-551 evidencing Permanent Residence for 1 year;" a. Canadian passports are not required to have a visa or I-94. b. Applicants from the Federated States of Micronesia, Palau, and the Republic of the Marshall Islands are not required to present a visa but must submit an I-94. c. Passports with I-94 indicating F-1/F-2 status must be submitted with a valid Form I-20. d. Passports with I-94 indicating J-1/J-2 status must be submitted with a valid Form DS-2019. e) Authorization for Parole of an Alien into the United States (I-512); f) Employment Authorization Card (I-668B or I-766); g) Form I-94 stamped with "Section 207" or "Section 208" status; h) Permanent Resident Card (I-551); i) Temporary Resident Card (I-688); j) Travel Document (I-131).

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Personal Disclosure Form 2

IMPORTANT NOTICES · · You may be required to provide additional information or submit additional forms. If at any time prior to receiving your permanent occupational license there are material changes to the information submitted herein, you must immediately notify the Commission in writing of the material changes. Return notarized copies of the attached Verification, Request to Release Information and Release of All Claims along with this Form. Pursuant to 68 IAC 2-3-2, this application must be accompanied by a two hundred dollar ($200) nonrefundable application fee. All fees must be submitted in the form of certified check or cashier's check made payable to the State of Indiana. All materials submitted to the Commission must be sent to:

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Indiana Gaming Commission Attention: Investigations Section East Tower Tower, Suite 1600 101 W. Washington Street Indianapolis, Indiana 46204-3408

If you have any questions about this Application or the occupational licensing process, contact either the Director of Financial Investigations or the Director of Background Investigations at (317) 233-0046.

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Personal Disclosure Form 2

DEFINITIONS
Terms in this Application shall have meanings ascribed to them in IC 4-33-2, IC 4-35-2 and/or 68 IAC 1-1. The following terms shall have the following meanings: Affiliate: Any Person who directly or indirectly Controls, is Controlled by, or is under common Control of another Person. Applicant: Any Individual or Business Entity who directly or indirectly has applied for a gaming license. Application: The total written materials, including the instructions, forms and other documents issued by the Commission, comprising Applicant's request for an Owner's License. Best of My Knowledge: Applicant's knowledge after substantial inquiry. Business Entity: Any of the following: partnership, incorporated or unincorporated association or group, firm, corporation, limited liability company, partnership for shares, trust, sole proprietorship or any other form of business. Casino: Any facility under the jurisdiction of the Commission pursuant to IC 4-33 or IC 4-35. Commission: The Indiana Gaming Commission. Compensation: Anything of value, including but not limited to salary, wages, commissions, tips, gratuities, fees, bonuses, and distributions from any Person, in any form, including cash, securities, real property and tangible and intangible personal property. Felony: A criminal offense for which a sentence of imprisonment of more than one (1) year may be imposed under the laws of any jurisdiction. Game: A banking, wagering, gambling, or percentage game or activity that is played for chips, tokens, or anything of value, including, without limitation, those played with cards; chips; tokens; dice; implements; or electronic, electrical, or electromechanical devices or machines. Gaming: The dealing, operating, carrying on, conducting, maintaining, or exposing for play of any Game. Gaming Entity: Any Business Entity or Affiliate thereof other than a governmental entity, a licensed accountant, architect, attorney, engineer or physician that either: (1) engages in Gaming, or (2) provides goods. Individual: Any natural Person. Key Person: Any officer, director, executive, employee, trustee, Substantial Owner, independent contractor, or agent of a Business Entity, having the power to exercise, either alone or in conjunction with others, management or operating authority over a Business Entity or Affiliate(s) thereof.

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Personal Disclosure Form 2

Person: An Individual, a sole proprietorship, a partnership, an association, a fiduciary, a corporation, a limited liability company, or any other Business Entity. Riverboat: Either of the following on which lawful gambling is authorized under the Riverboat Gambling Act: (1) a self-propelled excursion boat located in a county described in IC 4-33-1-1 or IC 4-33-1-1(2) that complies with IC 4-33-6-6-(a); or (2) a vessel located in a historic hotel district. Substantial Owner: Any: (1) Person who is not an Institutional Investor and who holds any direct, indirect, or attributed legal or beneficial interest whose combined direct, indirect, or attributed interest is five percent (5%) or more ownership interest in a Business Entity; or (2) Institutional Investor holding fifteen percent (15%) or more ownership interest in a Business Entity.

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Personal Disclosure Form 2

WARNING
Each question must be answered fully, accurately, and completely. ANY MISREPRESENTATION OR OMISSION CAN RESULT IN APPLICATION DENIAL. When information is unknown, so indicate by stating "Unknown". YOU MUST MAKE A SUBSTANTIAL INQUIRY TO DETERMINE THE ANSWERS TO ALL QUESTIONS.

Full Legal Name of Applicant: (First) Home Address: (Street) (Middle) (Last)

(City) Business Address:

(State)

(Zip Code)

(Street)

(City)

(State)

(Zip Code)

Home Business Telephone Number: (____) __________________ Telephone Number: (____) _____________ Social Security Number: Date of _______________________ Birth: (Month) (Day) (Year) Height: ___________________ Weight: __________________ Hair Color:

Color of Eyes: ________________ Sex: _____________________

Age: _______________

Email Address: Employer: Casino: Position:
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Personal Disclosure Form 2

TAPE PHOTOGRAPH HERE

TAPE BIRTH CERTIFICATE HERE (OR ACCEPTABLE SUBSTITUTE SEE INSTRUCTION ON PAGE 2)

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Personal Disclosure Form 2

1.

State any and all names used, legal or otherwise, other than the name stated on page 7. Include married names, maiden names, and aliases. Specify the dates of use for each name: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

2.

State whether you are a citizen of the United States: ______________________________ (a) If you are a naturalized citizen, state: place of naturalization, including Court granting naturalization:

date of naturalization: Petition number: Certificate number:

(b)

If you are an alien, state the "A" number from your Alien Registration Card: __________________________________________________________________

(c)

If you are an alien authorized to be employed in the United States but do not have an Alien Registration Card, state the "A" number of that authorization: __________________________________________________________________

3.

Provide two (2) completed fingerprint cards (Standard Blue Cards) with your Application. If you are employed at an Indiana Casino, see the Commission office to have your fingerprints scanned. Fingerprint cards will be provided upon request. If you are not employed at an Indiana Casino, you must have your fingerprints taken at a law enforcement agency.

4.

If you have ever served in any branch of the United States military or National Guard, whether active or inactive, please provide the following information:

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Personal Disclosure Form 2

(a)

The type of discharge or separation from military service (honorable, dishonorable, honorable conditions, medical, etc...): ______________________________________________________________________________

(b)

If you were ever court-martialed, tried on charges, or the subject of a summary court, deck court, captain's mast, company punishment, or the subject of any other disciplinary action while in military service, give details of the charges and their disposition: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

5.

If applicable, submit a copy of your military record (DD-214).

6.

List your Gaming-related work history, from age 18 to the present or the last twenty (20) years, whichever is less. Only include information for positions that were Gaming-related. Attach additional pages if necessary. For each position, provide the following: Dates Employed Company Name Position Supervisor

Company Address: Description of Duties: Reason You Left: Company Products & Services:

Dates Employed

Company Name

Position

Supervisor

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Personal Disclosure Form 2

Company Address: Description of Duties: Reason You Left: Company Products & Services:

Dates Employed

Company Name

Position

Supervisor

Company Address: Description of Duties: Reason You Left: Company Products & Services:

Dates Employed

Company Name

Position

Supervisor

Company Address: Description of Duties: Reason You Left: Company Products & Services:

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Personal Disclosure Form 2

7.

Have you ever been granted a Gaming license in any jurisdiction? If none, initial here ____________________ If yes, please provide the following information:

Dates Held

Jurisdiction

Type of License

Gaming Entity/Employer

Provide a detailed description of any disciplinary actions, restrictions, revocations, or non-renewals to which your license was subjected, including the date of the occurrence and your involvement in the situations or transactions that led to each incident: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

8.

Have you ever withdrawn an application for a gaming license from any jurisdiction? If no, initial here ____________________ If yes, include the following for each occurrence: Date Withdrawn

Jurisdiction

Reason for Withdrawal

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Personal Disclosure Form 2

9.

Do you currently have any outstanding Federal or State tax liabilities? If no, initial here ____________________

If yes, include the following for each occurrence: Federal or State Filing Year Amount Owed Payment Plan Description

NOTE:

FAILURE TO REPORT ANY ARREST, DETAINMENT, CHARGE, INDICTMENT, OR CONVICTION, WHETHER A MISDEMEANOR OR A FELONY, IS CAUSE FOR DENIAL OF LICENSURE.

10.

If you have ever been arrested, detained, charged, indicted, convicted, received a pre-trial diversion, pleaded guilty or nolo contendere, or forfeited bail concerning any criminal offense, either Felony or misdemeanor, in any state or foreign country (except for traffic violations where the maximum punishment is a fine under $500), provide the following for each case. Attach additional pages if necessary. If none, initial here __________________________ Disposition (Dismissed, Convicted, Acquitted, or Pending) or Sentence

Nature of Charge or Arrest

Date of Disposition

Name & Address of Governmental Agency or Court Involved

Felony or Misdemeanor

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Personal Disclosure Form 2

11.

If you have ever been adjudicated as bankrupt or filed a petition for any type of bankruptcy protection or insolvency, provide the following information: Date of Bankruptcy Bankruptcy Disposition Bankruptcy Cause Number

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Personal Disclosure Form 2

VERIFICATION

State of _____________________ SS:

County of ___________________

I, ____________________________________, being first duly sworn upon oath or affirmation, depose and state:

1. 2.

I am the individual who is submitting this form. I personally supplied the information contained in this form.

3. I swear (or affirm) that the information contained in this form is true, complete and accurate to the Best of My Knowledge and belief.

Individual's Signature: ___________________________________________________ Dated: _________________________ Before me, the undersigned, a Notary Public in and for said County and State, personally appeared __________________________________ and acknowledged the execution of the foregoing instrument at his/her voluntary act and deed.

WITNESS, my hand and Notarial Seal, this ____________ day of ___________, 20____.

________________________________________________ Notary public, Written Signature

________________________________________________ Notary public, Printed Name

My commission expires: _____________________ County of residence: _________________________

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Personal Disclosure Form 2

INDIVIDUAL'S REQUEST TO RELEASE INFORMATION TO: __________________________________________________ FROM: _______________________________________________ Individual's Name 1. I hereby authorize and request all persons or entities to whom this request is presented having information relating to or concerning me to furnish such information to a duly appointed agent of the Indiana Gaming Commission, whether or not such information would otherwise be protected from disclosure by any constitution, statutory or other legal privilege. 2. I hereby authorize and request all persons or entities to whom this request is presented having documents relating to or concerning me to permit a duly appointed agent of the Indiana Gaming Commission to review and copy any such documents, whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory or other legal privilege. 3. If the person or entity to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or any officer of same, I hereby authorize and request that a duly appointed agent of the Indiana Gaming Commission be permitted to review and obtain copies of any and all documents, records or correspondence pertaining to me, including but not limited to past loan information, notes co-signed by me, checking account records, savings deposit records, safe deposit box records, passbook records, and general ledger folio sheets. 4. I do hereby make, constitute, and appoint any duly appointed agent of the Indiana Gaming Commission my true and lawful agent for me in my name, place, stead, and on behalf and for my use and benefit in the retrieval of information, whether or not such information is considered confidential, but only in connection with the lawful background investigation required to ascertain my suitability for a gaming license. I do hereby authorize said agent: to request, review, copy, sign for, or otherwise act on my behalf for investigative purposes with (a) respect to documents and information in the possession of the person or entity to whom this request is presented as I might: to name the person or entity to whom this request is presented and insert that person's or entity's (b) name in the appropriate location on this request; (c) to place the name of the Indiana Gaming Commission agent presenting this request in the appropriate location on this request. 5. I grant to said agent full power and authority to request, review, copy, and perform all and every act and thing whatsoever requisite, proper, or necessary to be done, in the exercise of any of the rights and powers to gather information herein granted, as fully as to all intents and purposes as I might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said agent, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this authorization and rights and powers herein granted.
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Personal Disclosure Form 2

6. This authorization ends eighteen (18) months from the date of execution or at the termination of all licenses issued to Applicant/me by the Indiana Gaming Commission, whichever occurs later. 7. I do, for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the person or entity to whom this request is presented, and his or its agents and employees from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims, and demands whatsoever, known or unknown, in law or equity, which I ever had, now have, may have, or claim to have against the person or entity to whom this request is presented or his or its agents or employees arising out of or by reason of complying with this request. 8. I agree to indemnify and hold harmless the person or entity to whom this request is presented and his or its agents and employees from and against all claims, damages, losses, and expenses, including reasonable attorneys' fees arising out of or by reason of complying with this request. 9. A reproduction of this request by photocopy shall be for all intents and purposes as valid as the original.

IN WITNESS WHEREOF, I have executed this release at _____________________, (City) ____________________________ on the day of _____________________, 20_______. (State)

_________________________________________ Individual's Signature

_________________________________________ Printed Name

Before me, the undersigned, a Notary Public in and for said County and State, personally appeared _______________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed. WITNESS, my hand and Notarial Seal, this _____________ day of ________________, 20__________. _____________________________________ Notary Public, Written Signature

______________________________________ Notary Public, Printed Name My commission expires: ___________________________ County of residence: _______________________________
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Personal Disclosure Form 2

RELEASE OF ALL CLAIMS The undersigned has filed with the Indiana Gaming Commission ("Commission") certain forms and documents in connection with a written request for licensing by the Commission ("Application"). In consideration of the assurance by the Commission a determination of suitability of the undersigned will be made following the completion of a deliberate, intensive and thorough investigation of the undersigned, including but not limited to background, associates, and finances, the undersigned does for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the State of Indiana, the Commission, its members, agents, and employees, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which the undersigned ever had, now has, may have, or claim to have against any or all of said entities or individuals arising out of or by reason of the processing or investigation of or other action relating to the Application. I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance. IN WITNESS WHEREOF, I have executed this release at ___________________________, (City) _______________________, on the _______________ day of _________________, 20_____. (State) __________________________________ Individual's Signature

__________________________________ Printed Name

Before me, the undersigned, a Notary Public in and for said County and State, personally appeared _________________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed.

WITNESS, my hand and Notarial Seal, this ____________ day of _______________, 20______.

_______________________________________ Notary Public, Written Signature

________________________________________ Notary Public, Printed Name My commission expires: _______________________ County of residence: __________________________
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