OCCUPATIONAL LICENSE SEPARATION FROM SERVICE OR SUSPENSION
State Form 51891 (R/3-08) INDIANA GAMING COMMISSION
Licensee Identification
Last name First name Middle initial Maiden name
Address (number and street)
City
State
Zip code
Telephone number
SSN (last four digits) XXX-XX-____________
Occupational license number
Date of birth (month, day, year)
Department/division
Job title
Supervisor
Separation from Service
Date of separation from service (month, day, year)
Involuntary
Reason
Voluntary
Was the IGC badge collected?* Yes No If yes, attach badge to form. If no, reason why: * Pursuant to 68 IAC 2-3-9.2, the casino or supplier licensee must collect the identification badge issued by the Commission to an occupational licensee when the occupational licensee's employment with the casino or supplier licensee is terminated for any reason.
Suspension
Start date (month, day, year) End date (month, day, year)
Reason
Signatures
Signature of Human Resources employee
Print Name
Date (month, day, year)
Name of IGC Agent
Identification number
Date (month, day, year)