Vendor Principal 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
  • $500 application fee for each officer, director, partner, and/or owner of ten (10%) or more of a Gaming Vendor or $300 application fee for each officer, director, partner, and/or owner of ten (10% or more of a Non-Gaming Vendor
  • If this is a Non-Gaming Vendor that is publicly traded, submit your most current 10-K filing and a list of your officers and directors in lieu of this Principal Application
  • $80 application fee for each officer, director, partner, and/or owner of ten (10%) or more of a vendor not required to complete the 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


Physical Address
Mailing Address

Gender

ft. in. 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. Tribal Affiliation

C. 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


D. Marital Information

E. Information Regarding Current Spouse

F. Former Spouse(s)

G.Provide the following information for each person, other than your spouse, residing in your home:

H.Military Information

Have you ever served in the armed forces?

While in the military were you ever charged with any offense of disciplined?



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 businesses, corporations, and partnerships with which you are or have been associated with in the past 15 years as an owner, officer, director, active shareholder, partner or other related capacity.

#1

Gaming Related?


#2

Gaming Related?


#3

Gaming Related?


#4

Gaming Related?


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

B. Have you ever held or applied to a licensing or regulatory agency for an occupational license, permit, registration or certificate of any type, other than gaming, whether or not the license, permit or certificate was granted?

List the licensing or regulatory agency to which you have applied for a license, permit regulatory certificate whether or not such license, permit, registration, or certificate was granted.(Include any application denied, withdrawn and/or pending.)

#1


#2


#3




VII. Criminal History and Litigation

Certified copies of court disposition paperwork are required to be submitted for any criminal charges listed below.Failure to provide said documents may result in a delay of your application.Also, 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. Are you currently a party to any civil lawsuits?

Complete the following for each:

#1

#2

#3


B. In the previous ten (10) years, have you been involved in litigation alleging intentional misconduct?

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

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

Please complete the following for each:

#1

#2

#3


D. 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:

#1

#2

#3


E. 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


F. 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


G. 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




VII. Financial History Information

Please be advised that the Poarch Band of Creek Indians Tribal Gaming Commission will be running your credit report as part of the background investigation. Certain major credit issues may result in denial of your gaming license.

A. Have you ever filed bankruptcy?

Please describe:


B. Have you ever been delinquent or failed to file a tax report or remit any tax imposed by any government?

Please describe:


C. Have you ever had your state or federal personal income tax return audited or adjusted?

Please describe: