APPLICATION FOR POSITION CHANGE OR REPLACEMENT BADGE
State Form 53543 (3-08) INDIANA GAMING COMMISSION
Casino
Name:
OR
Supplier
Name:
Occupational 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
Position Change
*An increase in License level requires that a new application be completed
Current position
Current department/division
Current supervisor
Current license level*
New position
New department/division
New supervisor
New license level*
Effective date (month, day, year) Was the old IGC badge collected? Yes No
Human Resources authorization Signature: Date:
Reinstatement
*A license may be reinstated only if the applicant returns to the same employer within 60 days following separation of service
New position
New department/division
New supervisor
New license level
Reinstatement date* (month, day, year)
Human Resources authorization Signature: Date:
Lost/Damaged Badge or Name Change
Lost
New last name (if applicable)
Stolen
Damaged
Name Change
New middle initial New maiden name (if applicable)
New first name (if applicable)
Signatures
All costs in connection with the issuing of this IGC Badge will be billed to the Casino or Supplier. Any reimbursement on the part of the Applicant is the responsibility of the Casino or Supplier. The Applicant has been made aware that making a false statement on this application will be grounds for the revocation of same. All necessary steps have been taken to surrender previously issued IGC badge.
Signature of Applicant
Date (month, day, year)
Name of IGC Agent
Identification number
Date (month, day, year)