Free Indiana Junketeer Certificate of Registration Application.pmd - Indiana

INDIANA JUNKETEER CERTIFICATE OF REGISTRATION APPLICATION
State Form 53687 (7-08) INDIANA GAMING COMMISSION Approved by State Board of Accounts, 2008

Reset Form

For Official Use Only License Fee Paid Date Received Reviewed By Date Entered

*This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory for consideration to receive a certificate of registration.
INSTRUCTIONS: 1. This Form must be submitted by any individual seeking to be registered as a junketeer as well as Key Persons and Substantial Owners. 2. An applicant for a Junketeer Certificate of Registration is seeking a privilege. The burden of establishing qualifications to receive such a certificate of registration is at all times on the applicant. Applicant must accept any risk of adverse public notice, embarrassment, criticism, or other action, or financial loss which may result from action with respect to an application, or public disclosure of information requested in this form, and expressly waives any claim for damages as a result thereof. Information not called for in this form or in addition to that provided in response to this form may be requested. The applicant shall provide all information, documents, materials and certifications at applicant's sole expense and cost. 3. The applicant should respond to the questions contained herein to the best of his/her knowledge. Any misrepresentation or omission is grounds for application denial. 4. The applicant is under a continuing duty to disclose promptly any changes in the information provided in the application and requested materials submitted to the Commission. The duty to make such additional disclosures shall continue throughout any period of registration granted by the Commission. 5. The applicant must submit an annual registration fee of seventy-five dollars ($75). The annual registration fee applies from January 1, to December 31, and will not be prorated. 6. Mail the check and completed application to: Indiana Gaming Commission, Legal Division, 101 W. Washington Street, East Tower, Suite 1600, Indianapolis, Indiana 46204

Please complete the following for each person who owns, controls, or serves as a junketeer on behalf of the junket operator (Check all that apply)

Substantial Owner
Full legal name of applicant

Key Person

Junketeer

Home address (foreign applicants only) (number and street)

City

State/Province

ZIP/Postal code

Country

Name of junket operator

Business address (number and street)

City

State/Province

ZIP code/Postal code Country

Business telephone number

Email address

Social Security Number*

Date of birth (month, day, year)

Passport number (foreign applicants only)

Height

Weight

Hair color

Color of eyes

Sex

Age

Dates of employment with junket operator (month, day, year)

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Attach additional sheets if necessary.

Company Address: (number and street, city, state, and ZIP code)

Company Address: (number and street, city, state, and ZIP code)

Company Address: (number and street, city, state, and ZIP code)

Dates Employed (month, day, year)

Dates Employed (month, day, year)

Dates Employed (month, day, year)

Company Products & Services

Company Products & Services

Company Products & Services

Description of Duties:

Description of Duties:

Description of Duties:

Reason You Left:

Reason You Left:

Reason You Left:

Company Name

Company Name

Company Name

Work History (past five years)

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Position Position Position Supervisor Supervisor Supervisor

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Date of disposition City Date of disposition City Date of disposition City Date of disposition City

Name of governmental agency or court involved

Nature of charge or arrest

Name of governmental agency or court involved

Nature of charge or arrest

Name of governmental agency or court involved

Nature of charge or arrest

Name of governmental agency or court involved

Nature of charge or arrest

If you have ever been arrested, detained, charged, indicted, convicted, received a pre-trial diversion, pleaded guilty or nolo contendere, or forfeited bail concerning any criminal offense, in any state or foreign country (except for traffic violations where the maximum punishment is a fine under $500), provide the following for each case. Please include court documents if applicable. Attach additional pages if necessary.

Disposition (dismissed, convicted, acquitted, or pending) or sentence Felony or misdemeanor (if other, please list) Disposition (dismissed, convicted, acquitted, or pending) or sentence Felony or misdemeanor (if other, please list) Disposition (dismissed, convicted, acquitted, or pending) or sentence Felony or misdemeanor (if other, please list) Disposition (dismissed, convicted, acquitted, or pending) or sentence Felony or misdemeanor (if other, please list) Country Country Country Country Address (number and street) Address (number and street) Address (number and street) Address (number and street) State/Province State/Province State/Province State/Province If none, initial here ZIP code/Postal code ZIP code/Postal code ZIP code/Postal code ZIP code/Postal code

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Attach a recent photograph taken within the last six (6) months.

TAPE PHOTOGRAPH HERE

FINGERPRINT CARDS Please provide two (2) completed fingerprint cards (Standard Blue Cards) with your Application. Fingerprint cards will be provided upon request. If you are unable to have your fingerprints taken at an Indiana casino, you must have your fingerprints taken by another law enforcment agency or other qualified vendor.

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RELEASE OF ALL CLAIMS The undersigned has filed with the Indiana Gaming Commission ("Commission") certain forms and documents in connection with a written request for registration by the Commission ("Application"). In consideration of the assurance by the Commission, a determination of suitability of the undersigned will be made following the completion of a deliberate, intensive and thorough investigation of the undersigned, including but not limited to background, associates, and finances. The undersigned does for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the State of Indiana, the Commission, its members, agents, and employees, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which the undersigned ever had, now has, may have, or claim to have against any or all of said entities or individuals arising out of or by reason of the processing or investigation of or other action relating to the application. I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance. IN WITNESS WHEREOF, I have executed this release at ___________________________, (City) _______________________, on the _______________ day of _________________, 20_____. (State) __________________________________ Individual's Signature

__________________________________ Printed Name

Before me, the undersigned, a Notary Public in and for said County and State, personally appeared _________________________________ and acknowledged the execution of the foregoing instrument as his/her voluntary act and deed.

WITNESS, my hand and Notarial Seal, this ____________ day of _______________, 20______.

_______________________________________ Notary Public, Written Signature ________________________________________ Notary Public, Printed Name My commission expires: _______________________ County of residence: ___________________________

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VERIFICATION

State of _____________________ County of ___________________

) )SS )

I, ____________________________________, being first duly sworn upon oath or affirmation, depose and state:

1. 2.

I am the individual who is submitting this form. I personally supplied the information contained in this form.

3. I swear (or affirm) that the information contained in this form is true, complete and accurate to the best of my knowledge and belief.

Individual's Signature: ___________________________________________________ Dated: _________________________ Before me, the undersigned, a Notary Public in and for said County and State, personally appeared __________________________________ and acknowledged the execution of the foregoing instrument at his/her voluntary act and deed.

WITNESS, my hand and Notarial Seal, this ____________ day of ___________, 20____.

________________________________________________ Notary public, Written Signature

________________________________________________ Notary public, Printed Name

My commission expires: _____________________ County of residence: _________________________

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