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

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
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 $100 application fee for each non-gaming vendor employee submitting an application; $100 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

New Application Renewal

Date Submitted: Corporate EIN

Name

First Name Middle Name Last Name Maiden Name Alias(es)
(Nicknames, Maiden Name, Name Changes, Legal or Otherwise)
Email Address

Physical Address

Address City/State/Zip

Mailing Address

Address City/State/Zip

Employer Occupation Employer Address Employer City/State/Zip Business Telephone Home Telephone Fax Number Other Telephone Number

Date of Birth Age Place of Birth
(City, County, State and Country) Social Security Number

Gender

Male Female

Driver's License/ID Card Number
(Number and Issuing State)

Eye Color Hair Color Height feet inches Weight lbs Distinguishing Marks
(scars, tatoos, etc.) Please describe and indicate location

A. Citizenship Information

Are you a United States citizen?

Yes No

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

C. Tribal Affiliation

Are you a member of a federally recognized Indian tribe?

Yes No

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?

Yes No

E. Marital Information

Other

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.

Month & Year
From - To (MM/DD/YYYY)

Employer Name

City/State/Zip

Address

Title

Reason for Leaving

Telephone Number

Supervisor

Description of Duties

Gaming Related Business?

Yes No

Month & Year
From - To (MM/DD/YYYY)

Employer Name

City/State/Zip

Address

Title

Reason for Leaving

Telephone Number

Supervisor

Description of Duties

Gaming Related Business?

Yes No

Month & Year
From - To (MM/DD/YYYY)

Employer Name

City/State/Zip

Address

Title

Reason for Leaving

Telephone Number

Supervisor

Description of Duties

Gaming Related Business?

Yes No

Month & Year
From - To (MM/DD/YYYY)

Employer Name

City/State/Zip

Address

Title

Reason for Leaving

Telephone Number

Supervisor

Description of Duties

Gaming Related Business?

Yes No

Month & Year
From - To (MM/DD/YYYY)

Employer Name

City/State/Zip

Address

Title

Reason for Leaving

Telephone Number

Supervisor

Description of Duties

Gaming Related Business?

Yes No

Month & Year
From - To (MM/DD/YYYY)

Employer Name

City/State/Zip

Address

Title

Reason for Leaving

Telephone Number

Supervisor

Description of Duties

Gaming Related Business?

Yes No

III. Residences

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

Month & Year
From To

Number & Street

City & State

County

Rent/Own?

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.

Name Occupation Home Address Mailing Address Home Telephone Work Telephone Number of Years Known

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

A. Have you ever held or applied for a permit, license, or certificate related to gaming, whether or not such license permit, or certificate was granted?

Yes No

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?

Yes No

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?

Yes No

Please complete the following for each:

Agency

Nature of Investigation

Date

Disposition

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

Yes No

Please complete the following for each:

#1

Date

Court Location
(City/County/State)

Original Charge

Final Charge
(if amended or reduced)

Disposition

#2

Date

Court Location
(City/County/State)

Original Charge

Final Charge
(if amended or reduced)

Disposition

#3

Date

Court Location
(City/County/State)

Original Charge

Final Charge
(if amended or reduced)

Disposition

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

Yes No

Please complete the following for each:

#1

Date

Court Location (City/County/State)

Original Charge

Final Charge (if amended or reduced)

Disposition

#2

Date

Court Location (City/County/State)

Original Charge

Final Charge (if amended or reduced)

Disposition

#3

Date

Court Location (City/County/State)

Original Charge

Final Charge (if amended or reduced)

Disposition

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?

Yes No

Please complete the following for each:

#1

Date

Court Location (City/County/State)

Original Charge

Final Charge (if amended or reduced)

Disposition

#2

Date

Court Location (City/County/State)

Original Charge

Final Charge (if amended or reduced)

Disposition

#3

Date

Court Location (City/County/State)

Original Charge

Final Charge (if amended or reduced)

Disposition