Renewal Application

INSTRUCTIONS

1. Answer ALL requests for information COMPLETELY. Provide full names, dates, addresses and zip codes.  Avoid the use of abbreviations.

2. Be sure to complete the SIGNATURE DISCLAIMER at the bottom of this form.

3. In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by 25 U.S.C. 2701et seq. The purpose of the requested information is to determine the eligibility of individuals to be granted a gaming license. The information will be used by the Tribal gaming regulatory authorities and by the National Indian Gaming Commission members and staff who have need for the information in the performance of their official duties. The information may be disclosed to appropriate Federal, Tribal, State, local, or foreign law enforcement and regulatory agencies when relevant to civil, criminal or regulatory investigations or prosecutions or when pursuant to a requirement by a tribe or the National Indian Gaming Commission in connection with the issuance, denial, or revocation of a gaming license, or investigations of activities while associated with a tribe or a gaming operation. Failure to consent to the disclosures indicated in this notice will result in a tribe's being unable to license you for a primary management official or key employee position.

4. The disclosure of your Social Security Number (SSN) is voluntary. However, failure to supply a SSN may result in errors in processing your application.

5. A false statement on any part of your license application may be grounds for denying a license or the suspension or revocation of a license. Also, you may be punished by fine or imprisonment (U.S. Code, title 18, section 1001).

6. You MUST file an amendment to this application immediately upon the occurrence of an event that would change ANY answer on the Application. FAILURE TO DO SO MAY RESULT IN DENIAL OR WITHDRAWAL OF A LICENSE.



Have you been known by any other name since the date of your last application?




Mailing Address
 

Legal Address
(if different from your Mailing Address)



Gaming Facility


Job Title

(according to current license) for which this renewal license is being sought


Department

Job Category


Class



List each instance, since the date of your last Tribal Gaming License Application, in which you have been arrested, or taken into custody, or questioned, or accused formally or informally of any MISDEMEANOR OFFENSE or FELONY OFFENSE. You must disclose each instance even though charges may not have been formally brought against you or they were dismissed or your were acquitted or adjudication was withheld or a conviction was reversed, set aside or vacated or the record sealed or expunged and regardless of whether you have been told that you need not disclose any such instance. You need not include any parking violations.


Have you been arrested or taken into custody since your last application?



Please provide a description of any previous or ongoing gaming or business relationship with any Indian tribe, including any ownership interest in those businesses since the date of your last Tribal Gaming License Application.



Please provide a description of any previous or ongoing gaming or business relationship with the gaming industry in general, including any ownership interest in those businesses since your last Tribal Gaming License Application



Provide the name and address of any licensing or regulatory agency with which you have filed an application for a license or permit related to gaming, whether or not such license or permit was granted.



Oath

I do hereby swear:

  1. That I have read this application, including the instructions, and that my answers are to the best of my knowledge true and complete; and,
  2. That if I am approved for a Tribal Gaming License, I will adhere to all rules and regulations, whether Tribal, Federal, or state laws regarding the conduct of gaming on Indian lands.
  3. That I MUST file an amendment to this application immediately upon the occurrence of an event that would change ANY answer on this Application. FAILURE TO DO SO MAY RESULT IN DENIAL OR WITHDRAWAL OF A LICENSE.


If you are ready to SUBMIT your application, click on SUBMIT FORM.