Attachment A - Application For Approval Of Blackjack, Poker, Roulette, Craps, And Blackjack/poker Combination Variation Games - Colorado Division Of Gaming Page 4
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5INVESTIGATION AUTHORIZATION and
AUTHORIZATION TO RELEASE INFORMATION
I,
, hereby authorize the Colorado Limited Gaming Control
Commission, the Division of Gaming, the Colorado Bureau of Investigation and the Colorado Attorney General (hereafter,
the Investigatory Agencies) to conduct a complete investigation into my personal background, using whatever legal
means they deem appropriate. I hereby authorize any person or entity contacted by the Investigatory Agencies to provide
any and all such information deemed necessary by the Investigatory Agencies. I hereby waive any rights to confidentiality
in this regard.
I understand that by signing this authorization, credit and other financial record checks may be performed. I authorize any
consumer credit reporting agency and any financial institution to provide to the Investigatory Agencies a complete and
accurate record of such transactions that may have occurred with that institution, including, but not limited to, internal
banking memoranda, past and present loan applications, financial statements and any other documents relating to my
personal or business financial records in whatever form and wherever located.
I understand that by signing this authorization, a criminal history check will be performed. I authorize the Investigatory
Agencies to obtain and use from any source, any information concerning me contained in any type of criminal history
record files., wherever located. I understand that the criminal history record files contain records of arrests which may
have resulted in a disposition other than a finding of guilt (i.e., dismissed charges, or charges that resulted in a not guilty
finding). I understand that the information may contain listings of charges that resulted in suspended imposition of
sentence, even though I successfully completed the conditions of said sentence and was discharged pursuant to law. I
authorize the release of this type of information, even though this record may be designated as “confidential” or
“nonpublic” under the provisions of state or federal laws.
The Investigatory Agencies reserve the right to investigate all relevant information and facts to their satisfaction. I
understand that the Investigatory Agencies may conduct a complete and comprehensive investigation to determine the
accuracy of all information gathered. However, the State of Colorado, Investigatory Agencies, and other agents or
employees of the State of Colorado shall not be held liable for the receipt, use or dissemination of inaccurate information.
I, on behalf of myself, my spouse, my legal representatives, heirs, and assigns, hereby release, waive, discharge, and
agree to hold harmless, and otherwise waive liability as to the State of Colorado, Investigatory Agencies, and other agents
or employees of the State of Colorado for any damages resulting from any use, disclosure, or publication in any manner,
other than a willfully unlawful disclosure or publication, of any material or information acquired during inquiries,
investigations, or hearings.
Any information contained within my application, contained within any financial or personnel record, or otherwise found,
obtained, or maintained by the Investigatory Agencies, shall be accessible to law enforcement agents of this or any other
state, the government of the United States, any foreign country, or any Indian Tribe.
Printed Full Legal Name (Last, First, Middle)
Signature (Must be signed in front of two witnesses, or alternatively, a Notary Public)
Dated this
day of
19
.
,
(city)
(state)
Witness 1 Signature
Witness 2 Signature
Attachment A
Page 4 of 5
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