Attachment A - Application For Approval Of Blackjack, Poker, Roulette, Craps, And Blackjack/poker Combination Variation Games - Colorado Division Of Gaming

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ATTACHMENT A
This Attachment A must be completed by EVERY individual or business entity listed on the
Application for approval of Blackjack, Poker, Roulette, Craps, and Blackjack/Poker Combination
Variation Games. (Duplicate all five pages of this Attachment A, as needed.)
NAME (last, first, middle) OR Corporate Name
Maiden/Married Names Used (Full Name) OR Trade Name
Nicknames, Aliases, Etc. Used (Full Name)
Street Address
City
State
Zip
Length at this Address
Mailing Address
State
Zip
Have you ever been denied a
No
gaming licensed in Colorado
Yes, explain on a
or in any other state?
separate sheet
Do you hold a current Colorado support
No
Yes –provide license number and expiration date:
employee or key employee gaming license?
Social Security Number OR F.E.I.N Number
Other Social Security Numbers Used
Home Phone Number
Yes
No
If “Yes”, attach details.
Date of Birth
Driver’s license No. / State
Fax Phone Number, if any
Physical
Height
Weight
Hair Color
Eye Color
Sex
Scars/Tattoos
Explain on a
Appearance
M
F
Y
N
separate sheet
U. S. Citizen
Yes
No
If “No”, attach details and indicate Alien Registration Number here:
Below, list all addresses where you have lived during the past five years. Do not include addresses listed above. Attach separate sheet if necessary.
STREET AND NUMBER
CITY/STATE/ZIP
FROM
TO
Name of Spouse, if applicable
Spouse’s Date of Birth
Spouse’s AKA (Also Known As – maiden name, nickname, aliases, etc.)
Spouse’s Social Security Number
Person(s) you have filed a joint tax return with in the past five years.
Name of present employer
Occupation or Job Title
Employer’s Address
Describe your relationship to the game in this application. Attach additional sheets if necessary
Signature of Applicant
Date
Attachment A
Page 1 of 5

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