Free Indiana Junket Operator Certificate of Registration Application.pmd - Indiana

INDIANA JUNKET OPERATOR CERTIFICATE OF REGISTRATION APPLICATION
State Form 53686 (7-08) INDIANA GAMING COMMISSION Approved by State Board of Accounts, 2008

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

INSTRUCTIONS:

1. This Form must be submitted by applicants seeking to be registered as Junket Operators. 2. An application for Junket Operator Certificate of Registration shall not be processed by the Commission unless the applicant submits a written agreement or a statement of intent to do business with an Indiana casino licensee. An unregistered junket operator may negotiate with a casino, but may not provide junketeer services to a casino, prior to registration. 3. An applicant for a Junket Operator Certificate of Registration is seeking a privilege. The burden of establishing the qualifications to receive such a certificate of registration is at all times on the applicant. The 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 the applicant's sole expense and cost. 4. 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. 5. 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. 6. Applicant must submit a non-refundable application fee of two hundred fifty dollars ($250) to the commission and an annual registration fee of two hundred fifty dollars ($250). The applicant must also submit an annual registration fee of seventy-five dollars ($75) for each junketeer. The annual registration fee applies from January 1, to December 31, and will not be prorated. 7. Mail the check and completed application to: Indiana Gaming Commission, Legal Division, 101 W. Washington Street, East Tower, Suite 1600, Indianapolis, Indiana 46204

Complete legal name of Junket Operator

Business address (number and street)

City

State/Province

ZIP/Postal code

Country

Business telephone number

Federal Tax Identification number

State Tax Identification number (if applicable)

Registered agent

Registered agent's business address (number and street)

City

State

ZIP code

Business telephone number and fax number (if available)

Other gaming jurisdiction(s) where licensed, registered, or conducts business

Complete Legal Name of any Substantial Owner or Key Person

Title

Ownership Interest

Please attach the following exhibits: 1. Organizational and ownership chart showing all parent, subsidiary, sister companies, or affiliates of the applicant. 2. Management chart. 3. Junketeer Certificate of Registration Application (state form 53687) for all Substantial Owners, Key Persons, and Junketeers.

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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. 3.

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