Fillable Montana Personal/criminal History Statement

PERSONAL/CRIMINAL HISTORY STATEMENT (Page 2)

EMPLOYMENT HISTORY

List employment, self-employment, military, unemployment and school attendance for the last 10 consecutive years (include foreign residences).

If more space is needed, attach additional sheets in the same format.

Dates From - To:

TITLE:

SUPERVISOR:

EMPLOYER/SCHOOL:

REASON FOR LEAVING:

ADDRESS: (Street or Route)

City

County

State or Country

Zip Code

Dates From - To:

TITLE:

SUPERVISOR:

EMPLOYER/SCHOOL:

REASON FOR LEAVING:

ADDRESS: (Street or Route)

City

County

State or Country

Zip Code

Dates From - To:

TITLE:

SUPERVISOR:

EMPLOYER/SCHOOL:

REASON FOR LEAVING:

ADDRESS: (Street or Route)

City

County

State or Country

Zip Code

Have you ever been ﬁ red or asked to resign from any employment related to gambling  Yes

 No

If yes, explain: ___________________________________

_____________________________________________________________________________________________________________________

RESIDENCE INFORMATION

You must list all places of residence for the last 10 consecutive years (include foreign residences). List current residence ﬁ rst. If more space is needed,

attach additional sheets in same format.

STREET ADDRESS:

Dates From - To:

CITY:

COUNTY:

STATE OR COUNTRY:

ZIP CODE:

STREET ADDRESS:

Dates From - To:

CITY:

COUNTY:

STATE OR COUNTRY:

ZIP CODE:

CERTIFICATION AND AUTHORIZATION

"I certify under penalty of law that all answers and statements on page 1 and 2 are true, correct and complete. I understand that untruthful or misleading

answers are cause for denial of a license and/or revocation of any license granted. I hereby authorize the Gambling Control Division to investigate my

criminal history, financial records and other sources as necessary for licensing."

The Montana Department of Justice Gambling Investigation Bureau shall access and review State and Federal history records and shall make reasonable

efforts to make a determination whether you have been convicted of, or are under pending indictments for a crime that bears upon your ﬁ tness to be granted

a license.

You are entitled to (a) obtain a copy of any background check report and (b) challenge the accuracy and completeness of any information contained in

any such report and obtain a prompt determination as to the validity of such challenge before a ﬁ nal determination is made by the Montana Department of

Justice Gambling Investigation Bureau. Such a request for a copy of your criminal history record and any challenge to the accuracy of such record should be

addressed to the Montana Department of Justice Gambling Investigation Bureau.

SIGNATURE:

PLACE SIGNED: (City, County and State)

PRINT NAME:

DATE SIGNED:

FORM 10 REV 07/11