Gaming Commission 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 Tribe or the National Indian Gaming Commission in connection with the hiring or firing of an employee, the issuance or revocation of a gaming operation. Failure to consent to the disclosures indicated in this notice will result in the Tribe’s being unable to hire you in a primary management official or key employee position, or other positions as determined by the Tribe. The disclosure of your Social Security Number (SSN) is voluntary. However, failure to supply a SSN may result in errors in processing your application. Notice Regarding False Statements In signing this application, I understand that a false statement on any part of the application may be grounds for not hiring me, or for firing me after I begin work. Also, I understand that I may be punished by fine or imprisonment. (U.S. Code, title 18, Section 1001) License Fees: The level of fees for issuance or renewal of a gaming license, and the payment of such fees, shall be in accordance with tribal regulations. Special Instructions • Complete each question. If not applicable, indicate so with “N/A” • Please type or print all answers. Do not use pencil. Failure to do so will cause delays and/or denial of your application. • If needed, attach additional documents or explanation sheets • Submit two current passport quality photographs. Ensure the photograph is a full facial view. Write your name and social security number on the back of each picture. Identification Requirements As part of your application, we will require that you provide positive proof of your identity; including one or more of the following official documents:
• Certification of birth; • Valid driver’s license; • State identification card; • Military identification card; • Valid passport; or • Alien registration card, if you are a registered alien.
Applicants initials_______
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