Form 10 - Personal/criminal Historystatement Page 2
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1
2P
/C
H
S
(
2)
ERSONAL
RIMINAL
ISTORY
TATEMENT
PAGE
OFFENSE DATE
OFFENSE
CITY
COUNTY
STATE
DISPOSITION & DATE
L
H
:
ITIGATION
ISTORY
In the past 10 years, have you, as an individual, partner, member of company, owner, director or officer of a corporation, ever been a party to a lawsuit?
Yes
No
If yes, give details below. List all cases without exception, including bankruptcies. Use additional paper if necessary.
PLAINTIFF/ DEFENDANT
COURT & CASE NUMBER
CITY
COUNTY
STATE
DISPOSITION & DATE
Yes
No
Have you ever been fired or asked to resign from any gambling related employment?
If Yes, explain:
R
I
:
ESIDENCE
NFORMATION
List all places of residence for the last 2 years. Start with current address. Use additional paper if necessary.
Dates From – To:
Street Address:
City:
County:
State:
Zip:
Dates From – To:
Street Address:
City:
County:
State:
Zip:
Dates From – To:
Street Address:
City:
County:
State:
Zip:
C
A
:
ERTIFICATION AND
UTHORIZATION
The Montana Department of Justice Gambling Investigation Bureau shall access and review State and Federal history records and shall make
reasonable efforts to determine whether you have been convicted of, or are under pending charges for a crime that bears upon your suitability to
be granted a license. If such adverse information is obtained, you will be 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. A request for a copy of your criminal history record
and whether you dispute the accuracy of such record should be addressed to the Montana Department of Justice Gambling Investigations Bureau.
The procedures for obtaining a change, correction, or updating of your criminal history record are set forth at Title 28, Code of Federal
Regulations (CFR), Section 16.34S. If a change, correction, or update needs to be made to a Montana criminal history record, contact Montana
Criminal Records and Identification Services at DOJCRISS2@mt.gov or 406-444-3625.
I certify under penalty of law that all answers and statements made on this application 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 further understand that I may be
prosecuted for knowingly making an Unsworn False Statement, a misdemeanor (45-7-203 MCA), or tampering with public records or information,
a felony (45-7-208). I hereby authorize the Gambling Control Division to investigate my criminal history, financial records and other sources as
necessary for licensing.
Signature:
Date Signed:
Place Signed:
Print Name:
City
County
State
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