Gaming License Renewal Form - Saginaw Chippewa Tribal Gaming Commission (Page 2 of 2) in pdf

Read each statement CAREFULLY. Applicant must initial after each statement. By placing your initials after each statement, you

are attesting to your understanding of and your agreement to abide by the terms of each statement. Applicants are advised that the

application for a gaming license is an official document and misrepresentation or failure to reveal information requested may be

deemed to be sufficient cause for the refusal or the revocation of a license. An applicant for a gaming license is seeking the granting

of a privilege, and the burden of proving his or her qualifications to receive such a license is at all times on the applicant.

I hereby swear under oath that if the license I am applying for is granted, I will submit to the jurisdiction of the Tribe and the Tribal

Court. (

initial)

I hereby swear that neither I nor any member of my immediate family has a past or current financial interest, other than a salary

interest, in any gaming-related enterprise.

(

initial)

If I have a relative who has a past or current financial interest, other than a salary interest, in any gaming-related enterprise

anywhere, I hereby swear that the attached statement is a full disclosure of his/her name and the nature of the relationship.

(

initial)

I hereby agree to be photographed. (

initial)

I hereby swear under oath that I will abide by all applicable tribal and federal laws, regulations and policies. (

initial)

I have read, and I understand and approve of the following Privacy Act notice:

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the

information on this form is authorized by 25 U.S.C. 2701 et seq. The purpose of the requested information

is to determine the eligibility of individuals to be granted a gaming license. The information will be used

by the Tribal gaming regulatory authorities and the National Indian Gaming Commission (NIGC)

members and staff who have need for the information in the performance of their official duties. The

information may be disclosed by the Tribe or the NIGC to appropriate Federal, Tribal, State, local, or

foreign law enforcement and regulatory agencies when relevant to civil, criminal or regulatory

investigations or prosecutions or when pursuant to a requirement by a tribe or the NIGC in connection

with the issuance, denial, or revocation of a gaming license, or investigations of activities while associated

with a tribe or a gaming operation. Failure to consent to the disclosures indicated in this notice will result

in a tribe’s being unable to license you for a primary management official or key employee position.

(

initial)

The disclosure of your Social Security Number (SSN) is voluntary. However failure to supply SSN may

result in errors in processing your application.

I have read, and I understand and approve of the following False Statement notice:

A false statement on any part of your license application may be grounds

for denying of a license or the suspension or revocation of a license. Also,

you may be punished by fine or imprisonment (U.S. Code, Title 18,

Section 1001).

(

initial)

I hereby give my permission for the Saginaw Chippewa Indian Tribe of Michigan or its designee to request any documents or other

information required to completely investigate my background including, but not limited to, my criminal record, civil and criminal

judgments, employment and personal references, and credit history. (

initial)

A photostatic copy of this authorization and release will be deemed as effective and valid as the original. (____ initial)

I understand that the information I supplied in the Personal History Disclosure Form will be used by the SAGINAW CHIPPEWA

GAMING COMMISSION and/or the Division of Licensing and Compliance to request any documents or other information

required to completely investigate my background, including but not limited to, my criminal record, civil and criminal judgments,

credit history, education, and employment. (____ initial)

I hereby swear that all of the information contained herein is true and correct to the best of my knowledge and that I have withheld

nothing. (

initial)

Failure to pick up your renewed license by the tag expiration date will result in a charge of $10.00 per day. (____initial)

_________________

Signature

Date

__________________________________________________

Print Name

Gaming License Renewal Form - Saginaw Chippewa Tribal Gaming Commission Page 2

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