Free Notice and Order of Denial of Occupational License Application.pmd - Indiana

NOTICE AND ORDER OF DENIAL OF OCCUPATIONAL LICENSE APPLICATION
State Form 47368 (R3/11-08) INDIANA GAMING COMMISSION

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Applicant Identification
Last name First name Middle initial Maiden name

Address (number and street)

City

State

ZIP code

Telephone number

Date of birth (month, day, year)

Social Security Number (last four digits) XXX-XX-____________

Denial

Felony Conviction

Age of Applicant

Indiana Code 4-3-8-3 provides that the Commission may not issue an occupational license to an individual unless the individual: (1) is at least eighteen (18) years of age, and (2) has not been convicted of a felony under Indiana law, the laws of any other state, or the laws of the United States. Resolution 2008-91 delegates to Commission staff the authority to deny applicants from these two categories. Application date (month, day, year) License level applied for Position applied for

Felony convictions disclosed by applicant (if applicable)

Date of convictions (month, day, year) Sentence

Jurisdiction/Court of record

Notice
If you wish to request a hearing on your denial, you must submit a request in writing, postmarked no later than fifteen days after service of this notice to: Executive Director Indiana Gaming Commission 101 W. Washington Street, East Tower, Suite 1600 Indianapolis, IN 46204 Your request must: 1) Be in writing. 2) State your name, address, and telephone number 3) State in detail the reasons why and the facts upon which you rely to show that your license application should not have been denied. 4) Be signed, dated, and verified. The verification must be notarized and must contain a certification stating, "under the penalty of perjury, the undersigned has examined this request for hearing and to the best of my knowledge and belief it is true, complete, and correct." Commission staff will contact you with information regarding your request for hearing. Other requirements are located at 68 IAC 7-1. Notice of denial served on the applicant by personal service: delivered to: date: time:

You may also seek a felony waiver. To access information about eligibility for felony waiver and to download a felony waiver application, please visit the Commission's website at: http://www.in.gov/igc/2344.htm and scroll down to the "Felony Waivers" topic. Copy of this form has been forwarded to the Legal Division at the Indiana Gaming Commission Signature of the IGC agent delivering notice of denial Identification number Copy of this form has been provided to the casino Human Resources department