Attachment A - Application For Approval Of Blackjack, Poker, Roulette, Craps, And Blackjack/poker Combination Variation Games - Colorado Division Of Gaming Page 3
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5Applicant’s Printed Name (last, first, middle)
NOTICE: This Application Form is an official document. If you provide false information on this application and/or do not
disclose all information requested, your application is subject to denial or revocation, and you may be subject to criminal
prosecution. The Division of Gaming may conduct a complete background investigation and may check all sources of
information.
You are advised that it is better to disclose all information than face denial, revocation or criminal
prosecution.
CRIMINAL HISTORY
1.
Regardless of your answers on the previous page, since you turned age 18, have you ever
been arrested, served with a criminal summons, charged with, or convicted of ANY crime
YES*
NO
or offense in any manner?
You must include ALL arrests, charges, and convictions since the age of 18 regardless of the outcome, even if the
charges were dismissed or you were found not guilty.
You must include ALL arrests, charges and convictions regardless of the class of crime (felonies, misdemeanors,
and/or petty offenses).
You must include ALL serious traffic offenses, including DUI, DWAI, reckless driving, leaving the scene of an accident
(hit and run), driving under denial, suspension or revocation, or any other offense which resulted in your being taken
into custody.
NOTICE: Do not rely upon your understanding that an arrest or charge is “not supposed to be on your record.” A
criminal record was not cleared, erased, sealed or expunged unless you were given, and have in your possession, a
written order from a judge directing that action.
*If you answered YES, explain in detail on a separate sheet and attach it to your application. For each offense for which
you were arrested or charged, YOU MUST OBTAIN OFFICIAL DOCUMENTATION FROM THE COURT WHERE YOU
APPEARED, SHOWING THE FINAL DISPOSITION (OUTCOME) OF YOUR CASE. This information will include whether
you were found guilty or not guilty; and the penalty (money fine, time in jail or prison, or probation or deferred sentence). If
you received a deferred judgment, a deferred sentence, or probation, your documentation must include the date that you
were discharged or released from probation or other supervision.
FINANCIAL HISTORY
1.
Are you delinquent in the filing of any tax return with any taxing agency anywhere?
YES
NO
2.
Are you delinquent in the payment of any taxes, interest, or penalties due to any taxing
YES
NO
agency anywhere?
3.
Are you delinquent in the payment of any judgments due to any governmental agency
YES
NO
anywhere?
4.
Are you delinquent in the repayment of any government-insured student loans?
YES
NO
5.
Are you delinquent in the payment of any child support?
YES
NO
*If you answered YES to any of the questions above, give details on separate sheet and include any items currently under
formal dispute or legal appeal. Attach any documents to prove your settlement on this issue.
NOTICE: If you answered YES to any of the questions above, You MUST provide proof you have taken steps to resolve
the financial delinquency before being permitted to be associated with a proprietary table game in Colorado.
AFFIRMATION AND CONSENT
I state under penalty of perjury that the entire Attachment A and any statements, attachments, and supporting schedules
are true and correct, as they pertain to me, to the best of my knowledge and belief, and that this statement is executed
with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for
the denial of approval by the State of Colorado. Further, I am aware that later discovery of an omission or
misrepresentation made in the above statements may be grounds for the denial or revocation of the approval. I am
voluntarily submitting this application to the Colorado Limited Gaming Control Commission under oath with full knowledge
that I any be charged with perjury or other crimes for intentional omissions and misrepresentations pursuant to Colorado
law. I further consent to any background investigation necessary to determine my present and continuing suitability.
Signature of Applicant
Date
Attachment A
Page 3 of 5
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