Form 10 - Personal/criminal Historystatement

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Form 10

Rev 05/16

PERSONAL/CRIMINAL

HISTORY STATEMENT

Type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply.

Name of Applicant

Name of Business

(if applicable)

EASON FOR

PPLICATION



Gambling Operator

Manufacturer

Route Operator

Card Room Contractor

Non-Institutional Lender

Liquor Operator

Distributor

Card Dealer

Sports Tab Seller

Other

OSITION WITH

USINESS

Owner

Partner

Officer

Member LLC

Other

Shareholder

Key Employee/

Director

Member LLP

Manager

Name:

Maiden:

Social Security Number:

(Last, First, Middle)



Date of Birth:

Place of Birth:

Race:

Eye Color:

Hair Color:

Weight:

Height:

Male



Female

Home Address:

City:

County:

State:

Zip:

Home/Cell Phone:

Work Phone:

Mailing Address

City:

State:

Zip:

(if different than home address):

Email Address:



Driver’s License Number & State of Issuance:

Port/Date of Entry:

US Citizen:

Yes

If no, list entry visa/work permit number:

ICENSE

ISTORY

List any business licenses that you have ever held or applied for (including any that have been denied/revoked/suspended in any state). Use additional paper if necessary.

TYPE

LICENSE NUMBERS

BUSINESS NAME

STATE

LAST YEAR HELD

GAMBLING

LIQUOR

OTHER

ERSONAL

RIMINAL

ISTORY

TATEMENT

Answer YES to the questions even if your charges were dismissed, deferred, or otherwise changed.

In the past 10 years, have you ever been:



Arrested?

Placed on probation?

Yes

Charged with a misdemeanor or

Arrested or ticketed for alcohol-related



Yes

felony crime?

traffic offenses? (such as DUI, Per Se, etc.)

Convicted of a misdemeanor or



Are you currently on probation or parole?

Yes

felony crime?

Explain each charge fully. Use additional paper if necessary. False or incomplete information may result in denial, suspension or revocation of a license.

OFFENSE DATE

OFFENSE

CITY

COUNTY

STATE

DISPOSITION & DATE

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