Gaming License Application Form

Keweenaw Bay Indian Community Gaming Commission
READ EACH OF THE FOLLOWING STATEMENTS, INITIAL EACH STATEMENT TO SIGNIFY YOUR UNDERSTANDING AND SIGN BELOW.
(1) I hereby swear under oath that if the license I am applying for will be issued, I will submit to the jurisdiction of the Gaming Commission and the Tribal Court of the Keweenaw Bay Indian Community. Please initial. *

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(2) I hereby swear under oath that I will abide by all applicable Tribal and Federal laws, regulations and policies. Please initial. *

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(3) In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on 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 granted a gaming license. The information will be used by the Tribal gaming regulatory authorities 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 by the Tribe or the NIGC to appropriate Federal, Tribal, State, local, or foreign law enforcement and regulatory agencies when relevant to civil, criminal or regulatory investigations or prosecutions or when necessary pursuant to a requirement by a tribe of the National Indian Gaming Commission in connection with the issuance, denial, or revocation of a 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 license for a Primary Management Official of Key Employee position. The disclosure of your Social Security Number (SSN) is voluntary. However, failure to supply a SSN may result in errors in processing your application. Please initial. *

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(4) A false statement on any part of your license application may be grounds for denying a license or the suspension or revocation of a license. Also, you maybe punished by fine or imprisonment (U.S. Code, title 18, section 1001). Please initial. *

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(5) I hereby authorize the Gaming Commission or its designee to request and receive any documents or other information required to completely investigate my background, including, but not limited to, my criminal record, civil and criminal judgments, and financial status and accounts. Please initial. *

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(6) I hereby swear that all of the information contained in this application is true and correct to the best of my knowledge and that I have not withheld or omitted any information. Please initial. *

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Keweenaw Bay Indian Community Gaming Commission

Background Investigation Form
The following information is required to process your application. Use a typewriter or print your answers in the space provided. If necessary, attach additional pages and indicate that you have done so under the section to which the additional pages apply. If a particular section does not apply to you, write “Not Applicable” or “N/A” under that section.
Title and/or description of position applied for:*
Name*

First NameMiddle NameLast Name
Maiden or other names used (if applicable)
Social Security*
Date of Birth*
Place of Birth*
Driver's License Number and State Issued:*
Country of Citizenship*
Ethnicity*
MaleFemale
Languages (spoken or written)
Name and address of spouse (If applicable)
YesNo
If yes, provide enrollment number
YesNo
If yes, provide enrollment number of enrolled member.
YesNo
If yes, specify Tribe and provide enrollment number
B. Personal References

Provide the names, current addresses and telephone numbers of three personal references. The references must not be related to you and must not be residing at your address(es).
Name of Reference #1*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Telephone: *
Format: (000) 000-0000.
Work or Cell Phone:
Format: (000) 000-0000.
Best time/s of day to reach this reference*
Name of Reference #2*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Telephone: *
Format: (000) 000-0000.
Work or Cell Phone:
Format: (000) 000-0000.
Best time/s of day to reach this reference*
Name of Reference #3*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Telephone: *
Format: (000) 000-0000.
Work and Cell Phone:
Format: (000) 000-0000.
Best time/s of day to reach this reference*
C. Current Residence
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Telephone: *
Format: (000) 000-0000.
Work and Cell Phone:
Format: (000) 000-0000.
Date you began living at this address:*

MonthDayYear
Date
D. Previous Residences

Provide the addresses of all residences at which you have lived over the past five years. Include one personal reference who was acquainted with you during each period of residence listed.
YesNo
Previous Residence 1:*

Street Address

Street Address Line 2

CityState

Zip Code
Names of Reference
Home Telephone:
Home phone number of reference Format: (000) 000-0000.
Work or Cell Phone:
Work or Cell phone of reference Format: (000) 000-0000.
YesNo
Previous Residence 2:*

Street Address

Street Address Line 2

CityState

Zip Code
Names of Reference
Home Telephone:
Home phone of reference Format: (000) 000-0000.
Work or Cell Phone:
work or Cell phone of referenceFormat: (000) 000-0000.
YesNo
Previous Residence 3:*

Street Address

Street Address Line 2

CityState

Zip Code
Names of Reference
Home Telephone:
Home telephone of reference Format: (000) 000-0000.
Work or Cell Phone:
Work or Cell Phone of reference Format: (000) 000-0000.
E. Military History

List all branches of the military in which you have served. Provide the dates of service, the highest rank attained, and the type of discharge. Attach a copy of your form DD214.
YesNo
Branch of Services*
Dates of Service: Started

MonthDayYear
Date
Dates of Service: Ended

MonthDayYear
Date
Highest Rank Attained
Type of Discharge
YesNo
If you have not attached your DD214 explain why:
Section 2 – Employment History:
A. Current and Previous Employment

List each current employment position and each employment position that you have held over the past five (5) years, and provide the dates of employment, the name of the employer, the employer’s address, and the name of a contact person and a telephone number for that person.
YesNo
Employer 1:*
Your Position*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person*
Last Name, First Name
Telephone No.*
Format: (000) 000-0000.
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
YesNo
Employer 2:*
Your Position*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person*
Last Name, First Name
Telephone No:*
Format: (000) 000-0000.
Dates of Employment: From *

MonthDayYear
Date
Dates of Employment: To *

MonthDayYear
Date
B. Previous Employment with Indian Tribes

If you have previously been employed by an Indian Tribe, you must provide the name of the Tribe, the position that you held, the name, address, and telephone number of a contact person, and the dates of employment.
YesNo
Employer:*
Your Position
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person
Last Name, First Name
Telephone No.
Format: (000) 000-0000.
Dates of Employment: From To

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
C. Previous Employment with Gaming Business

If you have previously been employed by a gaming business, you must provide the name, address and telephone number of the business, the position that you held, the name of a contact person, and the dates of employment.
YesNo
Employer:*
Your Position
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person
Last Name, First Name
Telephone No.
Format: (000) 000-0000.
Dates of Employment: From

MonthDayYear
Date
Dates of Employment: To

MonthDayYear
Date
Section 3 – Business History:
A. Current and Previous Business Positions

List each current business position and each business position that you have held over the past five (5) years, and provide the ownership interests in those businesses, business addresses, the name of a contact person and a telephone number for that person.
YesNo
Business Position 1:*
Business Address
Ownership Interest
Contact Person
Telephone No.
Format: (000) 000-0000.
YesNo
Business Position 2:*
Business Address
Ownership Interest
Contact Person
Telephone No.
Format: (000) 000-0000.
B. Existing and Previous Business Relationships with Indian Tribes

Describe any existing and previous business relationship with an Indian Tribe, including ownership interests in those businesses.
YesNo
Business Relationship 1:*
Ownership Interest
Contact Person
Telephone No.
Format: (000) 000-0000.
YesNo
Business Relationship 2:*
Ownership Interest
Contact Person
Telephone No.
Format: (000) 000-0000.
C. Existing and Previous Business Relationship and/or Financial Interest with/in the Gaming Industry

Describe any existing and previous business relationship with and/or financial interest in the gaming industry generally, including ownership interests in those businesses.
YesNo
Business Relationship 1:*
Financial Interest 1:
Ownership Interest:
Contact Person
Telephone No.
Format: (000) 000-0000.
YesNo
Business Relationship 2:*
Financial Interest 2:
Ownership Interest:
Contact Person:
Telephone No.
Format: (000) 000-0000.
D. Existing and Previous Business Relationship and/or Financial Interest of Family Member with/in the Gaming Industry

Describe any existing and previous business relationship of any family member with or financial interest in the gaming industry generally, including ownership interests in those businesses.
YesNo
Family Member:*
Business Relationship:
Financial Interest:
Ownership Interest:
Contact Person:
Telephone No.
Format: (000) 000-0000.
YesNo
Family Member:*
Business Relationship:
Financial Interest:
Ownership Interest:
Contact person:
Telephone No.
Format: (000) 000-0000.
Section 4 – Gaming and Occupational Licenses and Permits:
A. Gaming Licenses and Permits

List the name, address and telephone number of any licensing or regulatory agency with which you have filed an application for a license or permit related to gaming, whether or not such license or permit was granted.
YesNo
Agency 1:*
Agency address
Telephone No:
Please enter a valid phone number.Format: (000) 000-0000.
GrantedDenied
If Granted, Expiration Date

MonthDayYear
Date
YesNo
Agency 2:*
Agency address
GrantedDenied
If Granted, Expiration Date

MonthDayYear
Date
B. Occupational Licenses and Permits

List the name, address and telephone number of any licensing or regulatory agency with which you have filed an application for an occupational license or permit, whether or not such license or permit was granted.
YesNo
Agency 1:*
Agency address
Telephone No.
Format: (000) 000-0000.
GrantedDenied
If Granted, Expiration Date

MonthDayYear
Date
YesNo
Agency 2:*
Agency address
Telephone No.
Format: (000) 000-0000.
GrantedDenied
If Granted, Expiration Date

MonthDayYear
Date
Section 5 – Criminal History:
YesNo
YesNo
Nature of Offense 1:*
Date you were arrested for this offense:

MonthDayYear
Date
Date you were charged for this offense:

MonthDayYear
Date
Name of Law Enforcement Agency
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState

Zip Code
Final Outcome EG> Guilty, Not Guilty, Dismissed
Date

MonthDayYear
Date
YesNo
Nature of Offense 2:
Date you were arrested for this offense:

MonthDayYear
Date
Date you were charged for this offense:

MonthDayYear
Date
Name of Law Enforcement Agency
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState

Zip Code
Final Outcome EG> Guilty, Not Guilty, Dismissed
Date

MonthDayYear
Date
YesNo
If answered yes provide the following information regarding the felony that you have been arrested or convicted of.
Nature of offense 1:
Date you were arrested for this offense:

MonthDayYear
Date
Date you were charged for this offense:

MonthDayYear
Date
Name of Law Enforcement Agency
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState

Zip Code
Final Outcome EG> Guilty, Not Guilty, Dismissed
Date

MonthDayYear
Date
YesNo
If answered yes provide the following information regarding each offense for which you had been arrested or which you were charged within the past 10 years that were expunged.
Nature of Offense 1:
Date you were arrested for this offense:

MonthDayYear
Date
Date you were charged for this offense:

MonthDayYear
Date
Name of Law Enforcement Agency
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState

Zip Code
Final Outcome EG> Guilty, Not Guilty, Dismissed
Date

MonthDayYear
Date
YesNo
Nature of Offense 2:
Date you were arrested for this offense:

MonthDayYear
Date
Date you were charged for this offense:

MonthDayYear
Date
Name of Law Enforcement Agency
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState

Zip Code
Final Outcome EG> Guilty, Not Guilty, Dismissed
Date

MonthDayYear
Date
Section 6 – Civil Actions or Suits:
List any past, pending or anticipated civil action or suit, including, but not limited to, divorce proceedings, bankruptcies, collections for fraud, misrepresentation or embezzlement, and traffic violations.
YesNo
Nature of Action or Suit 1:*
Date filed

MonthDayYear
Date
Names of the Parties
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
Date Action Resolved

MonthDayYear
Date
YesNo
Nature of Action or Suit 2:*
Date filed

MonthDayYear
Date
Names of the Parties
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Date Action Resolved:

MonthDayYear
Date
YesNo
Nature of Action or Suit 3*
Date filed

MonthDayYear
Date
Names of the Parties
Name of Court
Address of Court:

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
Date Action Resolved:

MonthDayYear
Date
Section 7 – Other Information:
YesNo
If yes, provide relevant details:
Sex
PLEASE ADD A PHOTO TAKEN OF YOURSELF IN THE LAST YEAR AND CURRENT COPY OF YOUR DRIVER'S LICENSE
Photo of yourself*
Driver's License*
Tribal Card*
Before submitting this, please ensure that you included the same information that you had on your job application. The gaming commission will be reviewing your original application along with this.
Agreement Notification: By signing below, you confirm that you understand and acknowledge the following: Once you have completed your gaming license application, you agree to notify the Human Resources department immediately if you no longer wish to be considered for a position with the Casino. *

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Should be Empty:

Keweenaw Bay Indian Community Gaming Commission

READ EACH OF THE FOLLOWING STATEMENTS, INITIAL EACH STATEMENT TO SIGNIFY YOUR UNDERSTANDING AND SIGN BELOW.

Keweenaw Bay Indian Community Gaming Commission

Section 2 – Employment History:

Section 3 – Business History:

Section 4 – Gaming and Occupational Licenses and Permits:

Section 5 – Criminal History:

Section 6 – Civil Actions or Suits:

Section 7 – Other Information:

Before submitting this, please ensure that you included the same information that you had on your job application. The gaming commission will be reviewing your original application along with this.