Attachment A - Application For Approval Of Blackjack, Poker, Roulette, Craps, And Blackjack/poker Combination Variation Games - Colorado Division Of Gaming Page 2
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5Applicant’s Printed Name (last, first, middle
Date
NOTICE:
This application form is an official document. If you provide false information on your
application and/or do not disclose all information the application asks, your application is subject to
denial or revocation, and you may be subject to criminal prosecution. The Division of Gaming will
conduct a complete background investigation and will check all sources of information. You are
advised that it is better to disclose all information than face denial, revocation or criminal prosecution.
If you need clarification of any of the following questions, please contact the Investigations Section at
any of the three Division of Gaming offices in Lakewood, Central City, or Cripple Creek.
1
Have you ever been convicted of any gambling related felony, at any time?
YES
NO
2
Have you ever been convicted of any felony involving theft by deception (including, but not
YES
NO
limited to, embezzlement and other thefts using fraud, trickery, scams, con games, illegal
schemes, etc.) at any time?
3
Have you ever been convicted of any felony involving fraud or misrepresentation (including, but
YES
NO
not limited, to, bad checks, fraud, forgery, perjury, tax or welfare fraud, and crimes involving
false documentation) at any time?
4
Have you served any sentence, including probation or parole, within the past 10 years upon
YES
NO
conviction for any felony, even if the conviction occurred more than 10 years ago?
5
Have you served any sentence, including probation or parole, within the past 10 years upon
YES
NO
conviction of any misdemeanor gambling-related offense, even if the conviction occurred more
than 10 years ago?
6
Have you served any sentence, including probation or parole, within the past 10 years upon
YES
NO
conviction of any misdemeanor theft by deception offense (including, but not limited to,
embezzlement and other thefts using fraud, trickery, scams, con games, illegal schemes, etc.),
even if the conviction occurred more than 10 years ago?
7
Have you served any sentence, including probation or parole, within the past 10 years following
YES
NO
a conviction of any misdemeanor involving fraud or misrepresentation (including, but not limited
to, bad checks, fraud, forgery, perjury, tax or welfare fraud, and crimes involving false
documentation), even if the conviction occurred more than 10 years ago?
8
Are you currently being prosecuted or facing pending charges, in any jurisdiction, for any of the
YES
NO
above offenses, or are you on a deferred prosecution or a deferred judgment and sentence for
any of the above offenses?
9
Have you ever been convicted of the crime of professional gambling, as defined by Colorado
YES
NO
law?
10
Are you a career offender or a member of a career offender cartel?, as those terms are defined
YES
NO
by Colorado law?
11
Have you ever refused to cooperate with any legislative body or other official investigatory body
YES
NO
involved in the investigation of crimes related to gaming, official corruption or organized crime?
If you answered YES to any of the above questions, you cannot be found
suitable for association with a proprietary table game. DO NOT CONTINUE
WITH OR TURN IN THIS APPLICATION.
I have thoroughly read and understand the questions above, and understand that I cannot be
approved to be associated with a proprietary game in Colorado if at any time in the future I can ever
answer “Yes” to any of the questions above.
Date
Signature of applicant
Attachment A
Page 2 of 5
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