Free Occupational License Separation from Service or Suspension.pmd - Indiana


File Size: 19.7 kB
Pages: 1
Date: March 10, 2008
File Format: PDF
State: Indiana
Category: Government
Author: ameans
Word Count: 157 Words, 1,097 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.in.us/icpr/webfile/formsdiv/51891.pdf

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OCCUPATIONAL LICENSE SEPARATION FROM SERVICE OR SUSPENSION
State Form 51891 (R/3-08) INDIANA GAMING COMMISSION

Licensee Identification
Last name First name Middle initial Maiden name

Address (number and street)

City

State

Zip code

Telephone number

SSN (last four digits) XXX-XX-____________

Occupational license number

Date of birth (month, day, year)

Department/division

Job title

Supervisor

Separation from Service
Date of separation from service (month, day, year)

Involuntary
Reason

Voluntary

Was the IGC badge collected?* Yes No If yes, attach badge to form. If no, reason why: * Pursuant to 68 IAC 2-3-9.2, the casino or supplier licensee must collect the identification badge issued by the Commission to an occupational licensee when the occupational licensee's employment with the casino or supplier licensee is terminated for any reason.

Suspension
Start date (month, day, year) End date (month, day, year)

Reason

Signatures

Signature of Human Resources employee

Print Name

Date (month, day, year)

Name of IGC Agent

Identification number

Date (month, day, year)