Vendor License Application

Privacy Act Notice

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information no this form is authorized by 25 U.S.C. 2701 et. seq. The purpose of the requested information is to determine the eligibility of individuals to be employed in a gaming operation. The information will be used by the Poarch Band of Creek Indians Tribal Gaming Commission and by the National Indian Gaming Commission (NIGC) members and staff who have need for the information in the performance of their official duties. The information may be disclosed to the 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 the Poarch Band of Creek Indians Tribal Gaming Commission or the National Indian Gaming Commission in connection with the issuance or revocation of 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 the Tribe's being unable to conduct business with your company.

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


Initial issuance of a gaming license and the licensee's ability to continue to maintain a gaming license is contingent upon initial and continuing approval required by any and all regulatory gaming agencies, including, but not limited to, NIGC and the Poarch Band of Creed Indians Gaming Commission. Licensee represents and warrants that it will remain in compliance with all applicable state, federal, local and tribal laws and regulations. Failure of any licensee to fully comply with such agencies and regulations is grounds for suspension, revocation, or termination of a licensee's gaming license.

Documents to be Submitted with this Application

  • Company/Principal/Employee Vendor Terms and Conditions Form (Print, Initial and Sign)
  • Company/Principal/Employee Vendor Release of Information Form (Print, Sign and Notarize)
  • Disclosure, Authorization, and Consent For Release of Background Information (Print, Complete and Sign)
  • Required Cover Sheet
  • Preceding year's tax returns for all non-publicly traded companies or preceding year's tax return if this is a renewal
  • Most current 10-K filing for all publicly traded companies
  • Preceding year's profit and loss statements if this is a renewal
  • An organizational chart of the business down to the department head level
  • A complete list of all stockholders or members showing the number of shares of record held by each for non-publicly traded companies and a complete list of all officers and directors for publicly traded companies
  • Business formation documentation (i.e. Articles of Incorporation, Articles of Organization, and Partnership Agreements)


Please complete all fields in the following application. For items that do not apply, indicate N/A. If more space is needed, attach separate sheets.

Type of Application


Physical Address

Mailing Address

A. Prior names and addresses of the company for the last five (5) years

C. Type of Business Structure

D. Contact for Company

G. Provide the following information for each officer, director, partner, or owner of ten percent (10%) or more of the business for non-publicly traded companies

Note: All changes in applicant's officers, directors, partners, and owners of 10% or more of the company must be reported immediately to the Poarch Band of Creek Indians Tribal Gaming Commission.

J. Will your business be investing in or loaning money to PCI Gaming Authority or any gaming enterprise?

K. Describe below any current or previous business relationship(s) with the gaming industry, including ownership interests in those businesses. For each, list the name of the business, address, nature of the business relationship, and dates of the relationship.

From To
From To

From To
From To

L. Does this business have any ownership or previous management, business relationship, or agreement with any Indian Tribe, or an ownership, financial, or management interest, either gaming or non-gaming related, in any tribal business?

M. Does any family member of any officer, director, partner or owner of 10% or more of the business have any financial interest in any business related to gaming?

N. Provide the names, addresses and telephone numbers of three (3) business references with whom you have regularly done business within the last five (5) years, plus one Bank reference

II. Licensing Information

A. Has the business ever applied to any licensing or regulatory agency for a license, permit or authorization related to gaming, whether or not such license, permit or authorization was granted?

III. Litigation

A. Is the business currently a party to any civil lawsuits?

B. In the previous ten years, has your company or any of its officers, directors, owners of 10% or more of the company been involved in litigation alleging intentional misconduct?

C. In the last ten years, has this business ever been the subject of any type of investigation by any governmental agency for any type of criminal or civil violation?

D. In the previous ten years, has this business ever been involved in any civil litigation alleging unfair or anti-competitive business practices or misleading advertising or violations of any security regulations?

E. Has this business ever been delinquent or failed to pay a tax report or remit any tax imposed by any government?

F. During the past five years has the business commenced any type of administrative or judicial complaints/actions against any governmental or regulator of gaming?

G. Has the company of any of its officers, directors, partners or owners of 10% or more of the company ever filed bankruptcy?

Please review your answers and when you are satisfied, please click on "Submit Form" below.