Free Occupational Licensee Annual Renewal Information Update.pmd - Indiana

OCCUPATIONAL LICENSEE ANNUAL RENEWAL / INFORMATION UPDATE
State Form 53544 (3-08) INDIANA GAMING COMMISSION

Pursuant to 68 IAC 2-3-9.1, all occupational licensees are under a continuing duty to advise a gaming agent of any changes in the information requested below within ten (10) calendar days of the change or occurrence of the event. INSTRUCTIONS: 1. Mark whether you are completing this form as part of an annual license renewal or to update the Commission regarding changes in your personal information 2. Complete the Employee Identification section 3. Provide any disclosures as appropriate 4. Read disclaimer and sign in the presence of a gaming agent

Annual Renewal
Licensee Identification
(This section is required)

Update of Information

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) Start date (month, day, year)

Department/division

Job title

Supervisor

Disclosures
(Complete this section as necessary)

Arrest, Indictment, Charge or Conviction Date (month, day, year) Charge Arresting agency Location Disposition

Notice of Exclusion Date (month, day, year) Jurisdiction/State Agency/Tribe

License Revocation or Suspension in another Jurisdiction Date (month, day, year) Jurisdiction/State Agency/Tribe

Action taken

Reason

Set forth any other information that may affect your suitability for licensure (attach additional sheets if necessary):

Signatures
I, the undersigned, under the penalty of perjury, have examined the above and to the best of my knowledge and belief, the information provided is true, complete, and correct. I understand that the Commission may conduct a background investigation on any occupational licensee and may require that all or any part of the investigation cost be charged to the occupational licensee. I am aware that falsification or omission of information may result in the initiation of a disciplinary action or the revocation of my occupational license. The Commission may also refuse to renew my occupational license if I no longer meet the statutory and regulatory requirements for suitability.

Signature of Licensee

Date (month, day, year)

Name of IGC Agent

Identification number

Date (month, day, year)