State Form 46781 - Personal Disclosure Form 2 Page 10

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Personal Disclosure Form 2
(a)
The type of discharge or separation from military service (honorable, dishonorable, honorable
conditions, medical, etc…):
______________________________________________________________________________
(b)
If you were ever court-martialed, tried on charges, or the subject of a summary court, deck court,
captain's mast, company punishment, or the subject of any other disciplinary action while in
military service, give details of the charges and their disposition:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5.
If applicable, submit a copy of your military record (DD-214).
6.
List your Gaming-related work history, from age 18 to the present or the last twenty (20) years,
whichever is less. Only include information for positions that were Gaming-related. Attach additional
pages if necessary. For each position, provide the following:
Dates
Company Name
Position
Supervisor
Employed
Company Address:
Description of Duties:
Reason You Left:
Company Products & Services:
Dates
Company Name
Position
Supervisor
Employed
10

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