Free Occupational License Intake Form.pmd - Indiana

OCCUPATIONAL LICENSE INTAKE FORM
State Form 47367 (R/3-08) INDIANA GAMING COMMISSION

*This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

Application date (month, day, year)

Casino

Last name

First name

Middle initial

Maiden name

Social Security Number* Address (number and street)

Position

Level

Department

City

State

County

Zip code

Telephone number

Citizenship

Date of birth

City of birth

State of birth

Height

Weight

Sex (circle one) Male Female

Age

CIRCLE THE CODES THAT APPLY

HAIR COLOR
Bald .............. BAL Brown ........... BRO Sandy ........... SDY Black ............. BLK Gray .............. GRY Maroon ......... MAR Albino ............ ALB Dark Brown ... DBR Light Brown ... LBR Olive .............. OLV Yellow ............ YEL White ....................... W Am. Indian/Alaskan ... I Black .................... BLK Gray/Part Gray ..... GRY White ................... WHI Blond/Strawberry ...... BLN Red/Auburn ............... RED

EYE COLOR
Blue ..................... BLU Green .................. GRN Pink ..................... PNK Brown....................... BRO Hazel ........................ HAZ

SKIN TONE
Black ................... BLK Fair ...................... FAR Medium ............... MED Ruddy ................. RUD Dark ........................ DRK Light ........................ LGT Medium Brown ........ MBR Sallow ..................... SAL

RACE
Black ................... B Multi-Racial ......... M Asian/Pacific Isl ......... A Hispanic .................... H

INDIANA GAMING COMMISSION USE ONLY BELOW THIS LINE

Proof of Identification Proof of Age Application complete and legible Interview complete
Agent Received by

Occlic Date entry complete Fingerprints taken Photograph taken Badge printed
*unless felony conviction

Application Scanned and Saved on S: Drive Email Application to Investigations

Identification number