Gc/bc Form 103 Schedule D - Individual Statement

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Division of Charitable Gaming
GC/BC Form 103 – Schedule D
Individual Statement
1.
Name of Individual: _______________________________ Title: ____________________________________
Business Name: ______________________________________________
2.
Residence Address: ________________________________ ______________________ ________ _________
Street Address
City
State
Zip Code
3.
Former Residence Address (past 10 years) (attach an additional sheet if necessary)
Street
City
State
Zip Code
From
To
_________________ / _______________ / _____ /________ // _____/_____/_____//_____/_____/_____
_________________ / _______________ / _____ /________ // _____/_____/_____//_____/_____/_____
4.
Personal Phone Number: (_____) ______ - _________
Business Phone Number: (_____) ______ - _______
E-Mail Address: ______________________________
5.
Social Security No.: ______ - ______ - ________
Date of Birth: _____ / _____ / _______
Citizenship: ________________________
Marital Status: ______________
Height: _____’ ______”
Weight: __________
Sex: M _____ F_____
6.
Provide Spouse’s Name:
_______________________________ ____________________ ____________________________________
(First and Maiden Name)
(Occupation)
(Address, if different)
7(a) Have you ever been convicted of a crime in this state or any other state? _____ yes _____ no
If yes, specify the crime and disposition on a separate sheet of paper.
7(b) If convicted of a misdemeanor or felony, you are required to provide our office with either a Certificate of
Relief from Civil Disabilities, a Certificate of Good Conduct or a Pardon. Attach a copy to this form.
Failure to provide this information will prevent you
from being authorized to represent this supplier in the
State of New York with regards to Games of Chance and Bingo sales.
8.
Are you a public employee or a public official, elected, appointed or sworn? _____ yes _____ no
If yes, describe in detail: _____________________________________________________________________
9(a) Have you ever been known by another name? ______________________________________________________
9(b) If yes, state such name: ______________________________________________________________________
10. Are you now or ever been a professional gambler or gambling promoter? ____ yes
____ no
11. Within the past five years have you conducted or assisted in the conduct of games of chance or bingo in any
capacity? ____ yes ____ no If yes, give details on a separate sheet of paper.
12. Within the past five years have you been engaged in or connected with anyone who was engaged in the sales or
rental of space, equipment, supplies or the rendering of services for games of chance or bingo?
____ yes ____ no
If yes, give details on a separate sheet of paper.
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Form 103 (Rev. 10/2015)

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