Gaming License Renewal Form - Saginaw Chippewa Tribal Gaming Commission printable pdf download

GAMING LICENSE RENEWAL FORM

RENEWAL FEE: $20

(cash, money order, or payroll deduction only)

$30 Processing Fee

Valid MI Driver’s License or MI ID required to renew

(

ADDRESS MUST MATCH WHAT IS ON THIS FORM UNLESS YOU ARE A STUDENT. STUDENT ID REQUIRED)

Position:

Date:

Saginaw Chippewa Tribal Member?

Name:

Last

First

Middle

Race

M/F

Other names used in the last year

SU M

W TH

Full time

Part time

Days Worked:

Shift worked:

AM/PM to

AM/PM

Social Security #

Driver’s License #

(optional)

Driver’s License Expiration Date:

Gaming License Expiration Date:

Date of Birth:

Complete Address:

Street

City

State

Zip

County:

Date moved into current address

Phone:

Department Work Phone:

Questions: Answer Yes or No

Do you presently have any financial or ownership interest with any gaming business?......................................................

Does a member of your immediate family have a past or current financial or ownership interest with any gaming

business?......................................................................................................................................................................................

Do you presently hold ownership in a non-gaming business? (include name, address, phone)…………………………...

Have you applied for a professional or business license in the past 12 months?..................................................................

Have you been arrested or charged with any crime in the past 12 months?.........................................................................

Have you been involved in any civil action (including divorce or financial litigation) in the past 12 months?.................

Do you have a pending criminal action against you?...............................................................................................................

Have you had any civil judgments against you in the past 12 months?.................................................................................

Have you had any traffic violations in the past 12 months?...................................................................................................

10.

Have you had any criminal judgments against you in the past 12 months?..........................................................................

11.

Have you claimed bankruptcy in the past 12 months?............................................................................................................

Have you held any other jobs in the past 12 months? (include company, address, phone, supervisor’s name)…………

12.

13.

Is there any other information which might bring into question your fitness to serve as a primary management

official, key employee, or other employee?..............................................................................................................................

IMPORTANT – If you have answered a “yes” to any of the questions, information that explains your answer must

accompany this form; attach a separate sheet.

Return to:

Saginaw Chippewa Tribal Gaming Commission

Employee’s initial:

7500 Soaring Eagle Blvd.

Mt. Pleasant, MI 48858

989-775-5700

rev.5/18/16

Office Use Only: Rec’d by:

SELC Compliance intake:_______Tag Exp._____________