State Form 46781 - Personal Disclosure Form 2

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INDIANA GAMING COMMISSION
East Tower, Suite 1600
101 W. Washington Street
Indianapolis, Indiana 46204-3408
PERSONAL DISCLOSURE FORM 2
This form must be submitted by Applicants seeking an Occupational License Level 2.
If a prospective Applicant has any questions about whether he/she should submit this form,
consult 68 Indiana Administrative Code 2-3 ( ) or
contact Indiana Gaming Commission staff.
This form is authorized as outlined by IC 4-33 and IC 4-35 and fulfills the application
requirements therein. Disclosure of this information is REQUIRED. Failure to provide
information could result in rejection of or delay in processing this application.
State Form 46781 (R/1-10)
Approved by State Board of Accounts, 2008

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