Employee 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.

Disclosure

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

  • Acknowledgement of Drug Testing Policy
  • Two identification photos
  • A copy of Drivers License & Social Security Card
  • Current DMV printout (if requested)
  • $300 application fee for each gaming vendor employee submitting an application or $150 application fee for each non-gaming vendor employee submitting an application; $80 application fee for all other vendor employees whose company is not required to complete a Vendor License Application

Instructions

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.


I. Personal History Information

Type of Application

Name

Physical Address
Mailing Address

Gender

feet inches lbs

A. Citizenship Information

Are you a United States citizen?

(Submit original naturalization document for verification)

Are you eligible for employment in this country?


B. List all languages that you speak or write other than English:

C. Tribal Affiliation

D. PCI Gaming Authority Affiliation

Do you have any family members or friends who work for PCI Gaming Authority or any of its gaming enterprises?

Provide the family member's name, address relationship, position held & supervisor's name


E. Marital Information


II. Employment History

Beginning with your CURRENT employment, listing all employers, periods of unemployment, school, assignments, volunteer activities, and military experience during the LAST 10 YEARS. Attach a separate sheet if necessary.

Gaming Related Business?


Gaming Related Business?


Gaming Related Business?


Gaming Related Business?


Gaming Related Business?


Gaming Related Business?



III. Residences

Please list all of your residences (most recent first) for the past 10 years:





IV. Reference

List name, address and telephone number of at least five (5) personal references that are not related to you. Include at least one (1) reference you were acquainted with during each period of residence listed in Section III above. Do not include relatives, present employer or your employees.



V. Business Interest

A. List all previous or existing business relationships with any Indian Tribe, including any ownership interest in those businesses:


B. Describe all previous or existing business relationships with the gaming industry, including any ownership interest in those businesses:



VI. Licensing Information

List below any licensing or regulatory agency (tribal, state or local) to which you have applied for a license, permit, or certificate related to gaming activities or lottery, whether or not such license, permit or certificate was granted (Include any applications denied, withdrawn and/or pending):

#1


#2


#3



VII. Criminal History and Litigation

Be advised that any criminal charges that are revealed during your background investigation that are not disclosed will result in a denial of your gaming license.

A. In the previous ten (10) years, have you been involved in litigation alleging intentional misconduct or been the subject of any type of investigation by any governmental agency for any criminal or civil violation?

Please list the case number, name of court, location of court, date, nature of claim, and disposition:


B. During the past five (5) years, have you commenced any type of administrative or judicial complaints/actions against any governmental agency or regulator of gaming?

Please complete the following for each:


C. Have you ever been convicted of or charged with a felony, or are you currently being prosecuted for a felony?

Please complete the following for each:

#1


#2


#3


D. Have you ever been convicted of or charged with a misdemeanor, or are you currently being prosecuted for a misdemeanor?

Please complete the following for each:

#1


#2


#3


E. Are you now, or have you ever been, charged with any crime (excluding minor traffic violations), whether or not convicted, that is not otherwise listed above?

Please complete the following for each:

#1


#2


#3